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Implementation Guide February 2016
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
copy Ministerio de Salud y Proteccioacuten Social
Departamento Administrativo de Ciencia Tecnologiacutea e Innovacioacuten ndash Colciencias
Implementation manual for evidence-based clinical practice guidelines in health services provider institutions in Colombia
ISBN 978-958-8903-08-8Bogotaacute Colombia2014
This document has been prepared under contract 478 2013 of Ministerio de Salud y Proteccioacuten Social and the Universidad de Antioquia
ALEJANDRO GAVIRIA URIBEMinister Of Heath And Social Protection
FERNANDO RUIZ GOacuteMEZDeputy Minister of Heath and Service Provision
NORMAN JULIO MUNtildeOZ MUNtildeOZDeputy Minister of Social Protection GERARDO BURGOS BERNALGeneral Secretary
JOSEacute LUIS ORTIZ HOYOSHead Quality Office
HEacuteCTOR EDUARDO CASTRO JARAMILLO Executive Director
AURELIO MEJIacuteA MEJIacuteA Deputy Director Health Technology Assessment
IVAacuteN DARIacuteO FLOacuteREZ GOacuteMEZDeputy Director Clinical Practice Guidelines JAVIER HUMBERTO GUZMANDeputy Director Implementation and knowledge transfer DIANA ESPERANZA RIVERA RODRIacuteGUEZ Deputy Director Participation and Deliberation
SANDRA LUCIacuteA BERNALDeputy Director Communications
Manual Developer Group
AuthorsAndreacutes Duarte OsorioThematic ExpertPontificia Universidad JaverianaPhysician and Surgeon Specialist in Family Medicine MSc in Clinical Epidemiology
Ana Marcela Torres AmayaThematic ExpertUniversidad Nacional de ColombiaPharmaceutical Chemist MSc in Clinical Epidemiology
Claudia Marcela VeacutelezThematic ExpertUniversidad de AntioquiaPhysician and surgeon Specialist in public health management and social security MSc in Clinical Science
Academic Director Rodrigo Pardo TurriagoUniversidad Nacional de ColombiaSurgeon Specialist in Clinical Neurology MSc in Clinical Epidemiology
Education TeamMichelle Corteacutes BarreacuteExpert in EducationPontificia Universidad JaverianaPhysician Masterrsquos in Education MSc in Clinical Epidemiology
Carlos Goacutemez RestrepoThematic ExpertPontificia Universidad JaverianaHospital Universitario San Ignacio Psychiatrist psychoanalyst psychiatrist liaison MSc in Clinical Epidemiology
Socialization TeamMariacutea del Pilar PastorExpert in Qualitative ResearchUniversidad de AntioquiaNurse MSc in Public Health PhD in Public Health Sciences
Vivian Marcela Molano SotoExpert in communicationUniversidad Nacional de Colombia Social communicator-Reporter MSc in Political Studies
Luz Helena Lugo AgudeloRepresentative CPG Developer GroupsUniversidad de AntioquiaMedical physiatrist MSc in Clinical Epidemiology
Vanesa Andreiacutena SeijasPilot Study SupportUniversidad de AntioquiaPhysician and surgeon
Leonardo Andreacutes Anchique Leal Systems EngineerAlianza Cinets website administrator
Fernando SuaacuterezExpert in Medical InformaticsUniversidad JaverianaGeneticist doctor MSc in Clinical Epidemiology and MSc in Bioinformatics and Medical Informatics
Administrative Support TeamClaudia Marcela VeacutelezManaging DirectorUniversidad de Antioquia
Paula Andrea Castro Garciacutea EconomistUniversidad de Antioquia
Claudia Espinosa Johnson Interpreter and Official Translator Member Colegio Colombiano de Traductores ndash CCTMinistry of Health and Social Protection
Participants in Manual Validation
Validation of Implementation Model
CPG Acute Coronary Syndrome
Juan Manuel SeniorInternist Hemodynamist CardiologistHospital San Vicente Fundacioacuten
Efraiacuten GoacutemezInternist CardiologistCliacutenica Shaio Sociedad Colombiana de Cardiologiacutea
Natalia Tamayo Internist CardiologistHospital San Vicente Fundacioacuten
Aacutengela DiacuteazAdministratorCliacutenica las Ameacutericas
Clara Ineacutes MejiacuteaPhysician auditCAPRECOM
Sebastiaacuten RuizRural doctorESE Copacabana
CPG Pregnancy
Joaquiacuten GoacutemezOB-GYN doctorUniversidad de Antioquia Director of Centro Nacer
Juan Guillermo LondontildeoOB-GYN doctorUniversidad de Antioquia NACER Group
Wilson MartiacutenezPhysicianMetrosalud
Luis Abel AldanaOB-GYN doctorHospital Marco Fidel Suaacuterez Bello and Cliacutenica Saludcoop Villa Nueva branch
Zaira RamiacuterezNurse Hospital Marco Fidel Suarez
Lina Mariacutea AriasPhysician Hospital Marco Fidel Suaacuterez de Bello
Moacutenica PatintildeoPhysician Metrosalud Unidad Hospitalaria de Manrique
Patricia ArbelaacuteezNurseMetrosalud Unidad Hospitalaria de Manrique
Arturo Cardona OspinaOB-GYN doctor Fetal Medicine SpecialistCliacutenica del Prado
Gloria CastantildeoNurse Cliacutenica del Prado
Johana ArangoNurse Cliacutenica del Prado
Manual Validation by Experts and System stakeholders
Ivaacuten Dariacuteo FloacuterezInstitute of Health Technology Assessment
Javier GuzmaacutenInstitute of Health Technology Assessment
Oscar Ariel Barragaacuten RiosQuality Office Ministry of Health and Social Protection
Indira Tatiana Caicedo ReveloQuality Office Ministry of Health and Social Protection
Hernando GaitaacutenHospital Universitario Universidad Nacional de Colombia
Jesuacutes EchavarriacuteaBogotaacute Health Office
Abel Ernesto Gonzaacutelez VeacutelezQuality Office Ministry of Health and Social Protection
Juan AlbornozCliacutenica de los Nogales
Lina Paola BonillaUniversidad Nacional de Colombia
Ana C FernaacutendezInstitute of Health Technology Assessment
Juan Manuel CorreaEPS Compensar
Jorge OrjuelaFundacioacuten Universidad Saacutenitas
Juan Pablo AlzateUniversidad Nacional de Colombia
Daniel Gonzalo EslavaUniversidad Javeriana
Pilot study ndash IPS SURA Medelliacuten
Clara Ximena SuaacuterezNational Audit Director of IPS Sura
Ana Catalina OchoaTechnical management analyst
Juan Carlos SuescuacutenEmergency Coordinator
Isabel Cristina FonnegraAuditor Basic IPS
Cesar Augusto CardonaInformation Analyst
Juan Esteban Holguiacuten Knowledge Management Analyst
Pilot study ndash Hospital de Fontiboacuten
Yidney Garciacutea RodriacuteguezManager
Nancy S Tabares RamiacuterezAssistant manager health services
Claudia P RoseroQuality leader
Liliana Castiblanco MososIntramural outpatient process leader
Marcela Saacutenchez CP and D Programs referent
Edgar FloacuterezAuditor
Diana NaranjoAuditor
Nancy ChacoacutenEpidemiologist
Clara Y PradaHospital Process Leader
Paola C GiraldoEmergency Process Leader
Pilot study ndash Hospital Universitario San Vicente Fundacioacuten
Fernando FortichInternist cardiologist
Yessica GiraldoGuideline group
Luz Marina QuicenoHead of Quality Assurance Office
Juan Fernando LondontildeoHead of Statistics Department
Yuli AgudeloResearch Unit Coordinator
Ministerio de Salud y Proteccioacuten Social - Colciencias 9
Content
1 INTRODUCTION 11
2 GLOSSARY 15
3 THE IMPLEMENTATION PROCESS IN THE COLOMBIAN SOCIAL SECURITY
SYSTEM IN HEALTH 19
31 National CPG Implementation Process 20
32 Scope and population under the CPG national implementation process 20
33 Roles for actors in the system 21
331 Ministry of Health and Social Protection (MSPS) 21
332 Institute for Health Technology Assessment (IETS) 21
333 Guideline Developer Groups (GDG) 22
334 Health Insurers (EPS or APB) 22
335 Health Service Provider Institutions 22
336 Higher Education Institutions 22
337ScientificSocieties 23
338 Associations of users and patients 23
339 Patients 23
4 PHASE 1 PLANNING AND CONSTRUCTION OF THE IMPLEMENTATION PLAN 25
41 CPG Adoption Policy 26
411 Steps for the adoption of CPG 26
42Establishmentoftheinstitutionalimplementationteamanddefinitionofroles 27
43 Creation of institutional implementation plan 27
431 Selection of the Guideline to implement 28
432Identificationofbarriersandfacilitators 28
433Definitionofstrategiesanddisseminationactivities 30
434 Selection of implementation tools 31
435Definitionoftheincentiveplan 31
436Identificationofresourcesneededforimplementation 32
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS10
437 Preparation of the schedule of activities 32
438 Selection of evaluation and control mechanisms 32
44 Preparation of Baseline 33
45Practicalstepsindefiningtheinstitutionalimplementationplan 33
46 Tips for creating the implementation plan 36
5 PHASE 2 REALIZATION OF IMPLEMENTATION ACTIVITIES 37
6 PHASE 3 IMPLEMENTATION MONITORING AND FOLLOW-UP 41
61 Monitoring 42
62 Evaluation plan for implementing CPG 42
621 Components of the evaluation 43
63 Feedback and adjustments to the implementation plan 43
7 IMPLEMENTATION OF PATIENT GUIDELINES 45
ANNEXES 47
BIBLIOGRAPHY 67
1 Introduction
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
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433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
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Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
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Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
copy Ministerio de Salud y Proteccioacuten Social
Departamento Administrativo de Ciencia Tecnologiacutea e Innovacioacuten ndash Colciencias
Implementation manual for evidence-based clinical practice guidelines in health services provider institutions in Colombia
ISBN 978-958-8903-08-8Bogotaacute Colombia2014
This document has been prepared under contract 478 2013 of Ministerio de Salud y Proteccioacuten Social and the Universidad de Antioquia
ALEJANDRO GAVIRIA URIBEMinister Of Heath And Social Protection
FERNANDO RUIZ GOacuteMEZDeputy Minister of Heath and Service Provision
NORMAN JULIO MUNtildeOZ MUNtildeOZDeputy Minister of Social Protection GERARDO BURGOS BERNALGeneral Secretary
JOSEacute LUIS ORTIZ HOYOSHead Quality Office
HEacuteCTOR EDUARDO CASTRO JARAMILLO Executive Director
AURELIO MEJIacuteA MEJIacuteA Deputy Director Health Technology Assessment
IVAacuteN DARIacuteO FLOacuteREZ GOacuteMEZDeputy Director Clinical Practice Guidelines JAVIER HUMBERTO GUZMANDeputy Director Implementation and knowledge transfer DIANA ESPERANZA RIVERA RODRIacuteGUEZ Deputy Director Participation and Deliberation
SANDRA LUCIacuteA BERNALDeputy Director Communications
Manual Developer Group
AuthorsAndreacutes Duarte OsorioThematic ExpertPontificia Universidad JaverianaPhysician and Surgeon Specialist in Family Medicine MSc in Clinical Epidemiology
Ana Marcela Torres AmayaThematic ExpertUniversidad Nacional de ColombiaPharmaceutical Chemist MSc in Clinical Epidemiology
Claudia Marcela VeacutelezThematic ExpertUniversidad de AntioquiaPhysician and surgeon Specialist in public health management and social security MSc in Clinical Science
Academic Director Rodrigo Pardo TurriagoUniversidad Nacional de ColombiaSurgeon Specialist in Clinical Neurology MSc in Clinical Epidemiology
Education TeamMichelle Corteacutes BarreacuteExpert in EducationPontificia Universidad JaverianaPhysician Masterrsquos in Education MSc in Clinical Epidemiology
Carlos Goacutemez RestrepoThematic ExpertPontificia Universidad JaverianaHospital Universitario San Ignacio Psychiatrist psychoanalyst psychiatrist liaison MSc in Clinical Epidemiology
Socialization TeamMariacutea del Pilar PastorExpert in Qualitative ResearchUniversidad de AntioquiaNurse MSc in Public Health PhD in Public Health Sciences
Vivian Marcela Molano SotoExpert in communicationUniversidad Nacional de Colombia Social communicator-Reporter MSc in Political Studies
Luz Helena Lugo AgudeloRepresentative CPG Developer GroupsUniversidad de AntioquiaMedical physiatrist MSc in Clinical Epidemiology
Vanesa Andreiacutena SeijasPilot Study SupportUniversidad de AntioquiaPhysician and surgeon
Leonardo Andreacutes Anchique Leal Systems EngineerAlianza Cinets website administrator
Fernando SuaacuterezExpert in Medical InformaticsUniversidad JaverianaGeneticist doctor MSc in Clinical Epidemiology and MSc in Bioinformatics and Medical Informatics
Administrative Support TeamClaudia Marcela VeacutelezManaging DirectorUniversidad de Antioquia
Paula Andrea Castro Garciacutea EconomistUniversidad de Antioquia
Claudia Espinosa Johnson Interpreter and Official Translator Member Colegio Colombiano de Traductores ndash CCTMinistry of Health and Social Protection
Participants in Manual Validation
Validation of Implementation Model
CPG Acute Coronary Syndrome
Juan Manuel SeniorInternist Hemodynamist CardiologistHospital San Vicente Fundacioacuten
Efraiacuten GoacutemezInternist CardiologistCliacutenica Shaio Sociedad Colombiana de Cardiologiacutea
Natalia Tamayo Internist CardiologistHospital San Vicente Fundacioacuten
Aacutengela DiacuteazAdministratorCliacutenica las Ameacutericas
Clara Ineacutes MejiacuteaPhysician auditCAPRECOM
Sebastiaacuten RuizRural doctorESE Copacabana
CPG Pregnancy
Joaquiacuten GoacutemezOB-GYN doctorUniversidad de Antioquia Director of Centro Nacer
Juan Guillermo LondontildeoOB-GYN doctorUniversidad de Antioquia NACER Group
Wilson MartiacutenezPhysicianMetrosalud
Luis Abel AldanaOB-GYN doctorHospital Marco Fidel Suaacuterez Bello and Cliacutenica Saludcoop Villa Nueva branch
Zaira RamiacuterezNurse Hospital Marco Fidel Suarez
Lina Mariacutea AriasPhysician Hospital Marco Fidel Suaacuterez de Bello
Moacutenica PatintildeoPhysician Metrosalud Unidad Hospitalaria de Manrique
Patricia ArbelaacuteezNurseMetrosalud Unidad Hospitalaria de Manrique
Arturo Cardona OspinaOB-GYN doctor Fetal Medicine SpecialistCliacutenica del Prado
Gloria CastantildeoNurse Cliacutenica del Prado
Johana ArangoNurse Cliacutenica del Prado
Manual Validation by Experts and System stakeholders
Ivaacuten Dariacuteo FloacuterezInstitute of Health Technology Assessment
Javier GuzmaacutenInstitute of Health Technology Assessment
Oscar Ariel Barragaacuten RiosQuality Office Ministry of Health and Social Protection
Indira Tatiana Caicedo ReveloQuality Office Ministry of Health and Social Protection
Hernando GaitaacutenHospital Universitario Universidad Nacional de Colombia
Jesuacutes EchavarriacuteaBogotaacute Health Office
Abel Ernesto Gonzaacutelez VeacutelezQuality Office Ministry of Health and Social Protection
Juan AlbornozCliacutenica de los Nogales
Lina Paola BonillaUniversidad Nacional de Colombia
Ana C FernaacutendezInstitute of Health Technology Assessment
Juan Manuel CorreaEPS Compensar
Jorge OrjuelaFundacioacuten Universidad Saacutenitas
Juan Pablo AlzateUniversidad Nacional de Colombia
Daniel Gonzalo EslavaUniversidad Javeriana
Pilot study ndash IPS SURA Medelliacuten
Clara Ximena SuaacuterezNational Audit Director of IPS Sura
Ana Catalina OchoaTechnical management analyst
Juan Carlos SuescuacutenEmergency Coordinator
Isabel Cristina FonnegraAuditor Basic IPS
Cesar Augusto CardonaInformation Analyst
Juan Esteban Holguiacuten Knowledge Management Analyst
Pilot study ndash Hospital de Fontiboacuten
Yidney Garciacutea RodriacuteguezManager
Nancy S Tabares RamiacuterezAssistant manager health services
Claudia P RoseroQuality leader
Liliana Castiblanco MososIntramural outpatient process leader
Marcela Saacutenchez CP and D Programs referent
Edgar FloacuterezAuditor
Diana NaranjoAuditor
Nancy ChacoacutenEpidemiologist
Clara Y PradaHospital Process Leader
Paola C GiraldoEmergency Process Leader
Pilot study ndash Hospital Universitario San Vicente Fundacioacuten
Fernando FortichInternist cardiologist
Yessica GiraldoGuideline group
Luz Marina QuicenoHead of Quality Assurance Office
Juan Fernando LondontildeoHead of Statistics Department
Yuli AgudeloResearch Unit Coordinator
Ministerio de Salud y Proteccioacuten Social - Colciencias 9
Content
1 INTRODUCTION 11
2 GLOSSARY 15
3 THE IMPLEMENTATION PROCESS IN THE COLOMBIAN SOCIAL SECURITY
SYSTEM IN HEALTH 19
31 National CPG Implementation Process 20
32 Scope and population under the CPG national implementation process 20
33 Roles for actors in the system 21
331 Ministry of Health and Social Protection (MSPS) 21
332 Institute for Health Technology Assessment (IETS) 21
333 Guideline Developer Groups (GDG) 22
334 Health Insurers (EPS or APB) 22
335 Health Service Provider Institutions 22
336 Higher Education Institutions 22
337ScientificSocieties 23
338 Associations of users and patients 23
339 Patients 23
4 PHASE 1 PLANNING AND CONSTRUCTION OF THE IMPLEMENTATION PLAN 25
41 CPG Adoption Policy 26
411 Steps for the adoption of CPG 26
42Establishmentoftheinstitutionalimplementationteamanddefinitionofroles 27
43 Creation of institutional implementation plan 27
431 Selection of the Guideline to implement 28
432Identificationofbarriersandfacilitators 28
433Definitionofstrategiesanddisseminationactivities 30
434 Selection of implementation tools 31
435Definitionoftheincentiveplan 31
436Identificationofresourcesneededforimplementation 32
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS10
437 Preparation of the schedule of activities 32
438 Selection of evaluation and control mechanisms 32
44 Preparation of Baseline 33
45Practicalstepsindefiningtheinstitutionalimplementationplan 33
46 Tips for creating the implementation plan 36
5 PHASE 2 REALIZATION OF IMPLEMENTATION ACTIVITIES 37
6 PHASE 3 IMPLEMENTATION MONITORING AND FOLLOW-UP 41
61 Monitoring 42
62 Evaluation plan for implementing CPG 42
621 Components of the evaluation 43
63 Feedback and adjustments to the implementation plan 43
7 IMPLEMENTATION OF PATIENT GUIDELINES 45
ANNEXES 47
BIBLIOGRAPHY 67
1 Introduction
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
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2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
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Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
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Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
ALEJANDRO GAVIRIA URIBEMinister Of Heath And Social Protection
FERNANDO RUIZ GOacuteMEZDeputy Minister of Heath and Service Provision
NORMAN JULIO MUNtildeOZ MUNtildeOZDeputy Minister of Social Protection GERARDO BURGOS BERNALGeneral Secretary
JOSEacute LUIS ORTIZ HOYOSHead Quality Office
HEacuteCTOR EDUARDO CASTRO JARAMILLO Executive Director
AURELIO MEJIacuteA MEJIacuteA Deputy Director Health Technology Assessment
IVAacuteN DARIacuteO FLOacuteREZ GOacuteMEZDeputy Director Clinical Practice Guidelines JAVIER HUMBERTO GUZMANDeputy Director Implementation and knowledge transfer DIANA ESPERANZA RIVERA RODRIacuteGUEZ Deputy Director Participation and Deliberation
SANDRA LUCIacuteA BERNALDeputy Director Communications
Manual Developer Group
AuthorsAndreacutes Duarte OsorioThematic ExpertPontificia Universidad JaverianaPhysician and Surgeon Specialist in Family Medicine MSc in Clinical Epidemiology
Ana Marcela Torres AmayaThematic ExpertUniversidad Nacional de ColombiaPharmaceutical Chemist MSc in Clinical Epidemiology
Claudia Marcela VeacutelezThematic ExpertUniversidad de AntioquiaPhysician and surgeon Specialist in public health management and social security MSc in Clinical Science
Academic Director Rodrigo Pardo TurriagoUniversidad Nacional de ColombiaSurgeon Specialist in Clinical Neurology MSc in Clinical Epidemiology
Education TeamMichelle Corteacutes BarreacuteExpert in EducationPontificia Universidad JaverianaPhysician Masterrsquos in Education MSc in Clinical Epidemiology
Carlos Goacutemez RestrepoThematic ExpertPontificia Universidad JaverianaHospital Universitario San Ignacio Psychiatrist psychoanalyst psychiatrist liaison MSc in Clinical Epidemiology
Socialization TeamMariacutea del Pilar PastorExpert in Qualitative ResearchUniversidad de AntioquiaNurse MSc in Public Health PhD in Public Health Sciences
Vivian Marcela Molano SotoExpert in communicationUniversidad Nacional de Colombia Social communicator-Reporter MSc in Political Studies
Luz Helena Lugo AgudeloRepresentative CPG Developer GroupsUniversidad de AntioquiaMedical physiatrist MSc in Clinical Epidemiology
Vanesa Andreiacutena SeijasPilot Study SupportUniversidad de AntioquiaPhysician and surgeon
Leonardo Andreacutes Anchique Leal Systems EngineerAlianza Cinets website administrator
Fernando SuaacuterezExpert in Medical InformaticsUniversidad JaverianaGeneticist doctor MSc in Clinical Epidemiology and MSc in Bioinformatics and Medical Informatics
Administrative Support TeamClaudia Marcela VeacutelezManaging DirectorUniversidad de Antioquia
Paula Andrea Castro Garciacutea EconomistUniversidad de Antioquia
Claudia Espinosa Johnson Interpreter and Official Translator Member Colegio Colombiano de Traductores ndash CCTMinistry of Health and Social Protection
Participants in Manual Validation
Validation of Implementation Model
CPG Acute Coronary Syndrome
Juan Manuel SeniorInternist Hemodynamist CardiologistHospital San Vicente Fundacioacuten
Efraiacuten GoacutemezInternist CardiologistCliacutenica Shaio Sociedad Colombiana de Cardiologiacutea
Natalia Tamayo Internist CardiologistHospital San Vicente Fundacioacuten
Aacutengela DiacuteazAdministratorCliacutenica las Ameacutericas
Clara Ineacutes MejiacuteaPhysician auditCAPRECOM
Sebastiaacuten RuizRural doctorESE Copacabana
CPG Pregnancy
Joaquiacuten GoacutemezOB-GYN doctorUniversidad de Antioquia Director of Centro Nacer
Juan Guillermo LondontildeoOB-GYN doctorUniversidad de Antioquia NACER Group
Wilson MartiacutenezPhysicianMetrosalud
Luis Abel AldanaOB-GYN doctorHospital Marco Fidel Suaacuterez Bello and Cliacutenica Saludcoop Villa Nueva branch
Zaira RamiacuterezNurse Hospital Marco Fidel Suarez
Lina Mariacutea AriasPhysician Hospital Marco Fidel Suaacuterez de Bello
Moacutenica PatintildeoPhysician Metrosalud Unidad Hospitalaria de Manrique
Patricia ArbelaacuteezNurseMetrosalud Unidad Hospitalaria de Manrique
Arturo Cardona OspinaOB-GYN doctor Fetal Medicine SpecialistCliacutenica del Prado
Gloria CastantildeoNurse Cliacutenica del Prado
Johana ArangoNurse Cliacutenica del Prado
Manual Validation by Experts and System stakeholders
Ivaacuten Dariacuteo FloacuterezInstitute of Health Technology Assessment
Javier GuzmaacutenInstitute of Health Technology Assessment
Oscar Ariel Barragaacuten RiosQuality Office Ministry of Health and Social Protection
Indira Tatiana Caicedo ReveloQuality Office Ministry of Health and Social Protection
Hernando GaitaacutenHospital Universitario Universidad Nacional de Colombia
Jesuacutes EchavarriacuteaBogotaacute Health Office
Abel Ernesto Gonzaacutelez VeacutelezQuality Office Ministry of Health and Social Protection
Juan AlbornozCliacutenica de los Nogales
Lina Paola BonillaUniversidad Nacional de Colombia
Ana C FernaacutendezInstitute of Health Technology Assessment
Juan Manuel CorreaEPS Compensar
Jorge OrjuelaFundacioacuten Universidad Saacutenitas
Juan Pablo AlzateUniversidad Nacional de Colombia
Daniel Gonzalo EslavaUniversidad Javeriana
Pilot study ndash IPS SURA Medelliacuten
Clara Ximena SuaacuterezNational Audit Director of IPS Sura
Ana Catalina OchoaTechnical management analyst
Juan Carlos SuescuacutenEmergency Coordinator
Isabel Cristina FonnegraAuditor Basic IPS
Cesar Augusto CardonaInformation Analyst
Juan Esteban Holguiacuten Knowledge Management Analyst
Pilot study ndash Hospital de Fontiboacuten
Yidney Garciacutea RodriacuteguezManager
Nancy S Tabares RamiacuterezAssistant manager health services
Claudia P RoseroQuality leader
Liliana Castiblanco MososIntramural outpatient process leader
Marcela Saacutenchez CP and D Programs referent
Edgar FloacuterezAuditor
Diana NaranjoAuditor
Nancy ChacoacutenEpidemiologist
Clara Y PradaHospital Process Leader
Paola C GiraldoEmergency Process Leader
Pilot study ndash Hospital Universitario San Vicente Fundacioacuten
Fernando FortichInternist cardiologist
Yessica GiraldoGuideline group
Luz Marina QuicenoHead of Quality Assurance Office
Juan Fernando LondontildeoHead of Statistics Department
Yuli AgudeloResearch Unit Coordinator
Ministerio de Salud y Proteccioacuten Social - Colciencias 9
Content
1 INTRODUCTION 11
2 GLOSSARY 15
3 THE IMPLEMENTATION PROCESS IN THE COLOMBIAN SOCIAL SECURITY
SYSTEM IN HEALTH 19
31 National CPG Implementation Process 20
32 Scope and population under the CPG national implementation process 20
33 Roles for actors in the system 21
331 Ministry of Health and Social Protection (MSPS) 21
332 Institute for Health Technology Assessment (IETS) 21
333 Guideline Developer Groups (GDG) 22
334 Health Insurers (EPS or APB) 22
335 Health Service Provider Institutions 22
336 Higher Education Institutions 22
337ScientificSocieties 23
338 Associations of users and patients 23
339 Patients 23
4 PHASE 1 PLANNING AND CONSTRUCTION OF THE IMPLEMENTATION PLAN 25
41 CPG Adoption Policy 26
411 Steps for the adoption of CPG 26
42Establishmentoftheinstitutionalimplementationteamanddefinitionofroles 27
43 Creation of institutional implementation plan 27
431 Selection of the Guideline to implement 28
432Identificationofbarriersandfacilitators 28
433Definitionofstrategiesanddisseminationactivities 30
434 Selection of implementation tools 31
435Definitionoftheincentiveplan 31
436Identificationofresourcesneededforimplementation 32
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS10
437 Preparation of the schedule of activities 32
438 Selection of evaluation and control mechanisms 32
44 Preparation of Baseline 33
45Practicalstepsindefiningtheinstitutionalimplementationplan 33
46 Tips for creating the implementation plan 36
5 PHASE 2 REALIZATION OF IMPLEMENTATION ACTIVITIES 37
6 PHASE 3 IMPLEMENTATION MONITORING AND FOLLOW-UP 41
61 Monitoring 42
62 Evaluation plan for implementing CPG 42
621 Components of the evaluation 43
63 Feedback and adjustments to the implementation plan 43
7 IMPLEMENTATION OF PATIENT GUIDELINES 45
ANNEXES 47
BIBLIOGRAPHY 67
1 Introduction
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
HEacuteCTOR EDUARDO CASTRO JARAMILLO Executive Director
AURELIO MEJIacuteA MEJIacuteA Deputy Director Health Technology Assessment
IVAacuteN DARIacuteO FLOacuteREZ GOacuteMEZDeputy Director Clinical Practice Guidelines JAVIER HUMBERTO GUZMANDeputy Director Implementation and knowledge transfer DIANA ESPERANZA RIVERA RODRIacuteGUEZ Deputy Director Participation and Deliberation
SANDRA LUCIacuteA BERNALDeputy Director Communications
Manual Developer Group
AuthorsAndreacutes Duarte OsorioThematic ExpertPontificia Universidad JaverianaPhysician and Surgeon Specialist in Family Medicine MSc in Clinical Epidemiology
Ana Marcela Torres AmayaThematic ExpertUniversidad Nacional de ColombiaPharmaceutical Chemist MSc in Clinical Epidemiology
Claudia Marcela VeacutelezThematic ExpertUniversidad de AntioquiaPhysician and surgeon Specialist in public health management and social security MSc in Clinical Science
Academic Director Rodrigo Pardo TurriagoUniversidad Nacional de ColombiaSurgeon Specialist in Clinical Neurology MSc in Clinical Epidemiology
Education TeamMichelle Corteacutes BarreacuteExpert in EducationPontificia Universidad JaverianaPhysician Masterrsquos in Education MSc in Clinical Epidemiology
Carlos Goacutemez RestrepoThematic ExpertPontificia Universidad JaverianaHospital Universitario San Ignacio Psychiatrist psychoanalyst psychiatrist liaison MSc in Clinical Epidemiology
Socialization TeamMariacutea del Pilar PastorExpert in Qualitative ResearchUniversidad de AntioquiaNurse MSc in Public Health PhD in Public Health Sciences
Vivian Marcela Molano SotoExpert in communicationUniversidad Nacional de Colombia Social communicator-Reporter MSc in Political Studies
Luz Helena Lugo AgudeloRepresentative CPG Developer GroupsUniversidad de AntioquiaMedical physiatrist MSc in Clinical Epidemiology
Vanesa Andreiacutena SeijasPilot Study SupportUniversidad de AntioquiaPhysician and surgeon
Leonardo Andreacutes Anchique Leal Systems EngineerAlianza Cinets website administrator
Fernando SuaacuterezExpert in Medical InformaticsUniversidad JaverianaGeneticist doctor MSc in Clinical Epidemiology and MSc in Bioinformatics and Medical Informatics
Administrative Support TeamClaudia Marcela VeacutelezManaging DirectorUniversidad de Antioquia
Paula Andrea Castro Garciacutea EconomistUniversidad de Antioquia
Claudia Espinosa Johnson Interpreter and Official Translator Member Colegio Colombiano de Traductores ndash CCTMinistry of Health and Social Protection
Participants in Manual Validation
Validation of Implementation Model
CPG Acute Coronary Syndrome
Juan Manuel SeniorInternist Hemodynamist CardiologistHospital San Vicente Fundacioacuten
Efraiacuten GoacutemezInternist CardiologistCliacutenica Shaio Sociedad Colombiana de Cardiologiacutea
Natalia Tamayo Internist CardiologistHospital San Vicente Fundacioacuten
Aacutengela DiacuteazAdministratorCliacutenica las Ameacutericas
Clara Ineacutes MejiacuteaPhysician auditCAPRECOM
Sebastiaacuten RuizRural doctorESE Copacabana
CPG Pregnancy
Joaquiacuten GoacutemezOB-GYN doctorUniversidad de Antioquia Director of Centro Nacer
Juan Guillermo LondontildeoOB-GYN doctorUniversidad de Antioquia NACER Group
Wilson MartiacutenezPhysicianMetrosalud
Luis Abel AldanaOB-GYN doctorHospital Marco Fidel Suaacuterez Bello and Cliacutenica Saludcoop Villa Nueva branch
Zaira RamiacuterezNurse Hospital Marco Fidel Suarez
Lina Mariacutea AriasPhysician Hospital Marco Fidel Suaacuterez de Bello
Moacutenica PatintildeoPhysician Metrosalud Unidad Hospitalaria de Manrique
Patricia ArbelaacuteezNurseMetrosalud Unidad Hospitalaria de Manrique
Arturo Cardona OspinaOB-GYN doctor Fetal Medicine SpecialistCliacutenica del Prado
Gloria CastantildeoNurse Cliacutenica del Prado
Johana ArangoNurse Cliacutenica del Prado
Manual Validation by Experts and System stakeholders
Ivaacuten Dariacuteo FloacuterezInstitute of Health Technology Assessment
Javier GuzmaacutenInstitute of Health Technology Assessment
Oscar Ariel Barragaacuten RiosQuality Office Ministry of Health and Social Protection
Indira Tatiana Caicedo ReveloQuality Office Ministry of Health and Social Protection
Hernando GaitaacutenHospital Universitario Universidad Nacional de Colombia
Jesuacutes EchavarriacuteaBogotaacute Health Office
Abel Ernesto Gonzaacutelez VeacutelezQuality Office Ministry of Health and Social Protection
Juan AlbornozCliacutenica de los Nogales
Lina Paola BonillaUniversidad Nacional de Colombia
Ana C FernaacutendezInstitute of Health Technology Assessment
Juan Manuel CorreaEPS Compensar
Jorge OrjuelaFundacioacuten Universidad Saacutenitas
Juan Pablo AlzateUniversidad Nacional de Colombia
Daniel Gonzalo EslavaUniversidad Javeriana
Pilot study ndash IPS SURA Medelliacuten
Clara Ximena SuaacuterezNational Audit Director of IPS Sura
Ana Catalina OchoaTechnical management analyst
Juan Carlos SuescuacutenEmergency Coordinator
Isabel Cristina FonnegraAuditor Basic IPS
Cesar Augusto CardonaInformation Analyst
Juan Esteban Holguiacuten Knowledge Management Analyst
Pilot study ndash Hospital de Fontiboacuten
Yidney Garciacutea RodriacuteguezManager
Nancy S Tabares RamiacuterezAssistant manager health services
Claudia P RoseroQuality leader
Liliana Castiblanco MososIntramural outpatient process leader
Marcela Saacutenchez CP and D Programs referent
Edgar FloacuterezAuditor
Diana NaranjoAuditor
Nancy ChacoacutenEpidemiologist
Clara Y PradaHospital Process Leader
Paola C GiraldoEmergency Process Leader
Pilot study ndash Hospital Universitario San Vicente Fundacioacuten
Fernando FortichInternist cardiologist
Yessica GiraldoGuideline group
Luz Marina QuicenoHead of Quality Assurance Office
Juan Fernando LondontildeoHead of Statistics Department
Yuli AgudeloResearch Unit Coordinator
Ministerio de Salud y Proteccioacuten Social - Colciencias 9
Content
1 INTRODUCTION 11
2 GLOSSARY 15
3 THE IMPLEMENTATION PROCESS IN THE COLOMBIAN SOCIAL SECURITY
SYSTEM IN HEALTH 19
31 National CPG Implementation Process 20
32 Scope and population under the CPG national implementation process 20
33 Roles for actors in the system 21
331 Ministry of Health and Social Protection (MSPS) 21
332 Institute for Health Technology Assessment (IETS) 21
333 Guideline Developer Groups (GDG) 22
334 Health Insurers (EPS or APB) 22
335 Health Service Provider Institutions 22
336 Higher Education Institutions 22
337ScientificSocieties 23
338 Associations of users and patients 23
339 Patients 23
4 PHASE 1 PLANNING AND CONSTRUCTION OF THE IMPLEMENTATION PLAN 25
41 CPG Adoption Policy 26
411 Steps for the adoption of CPG 26
42Establishmentoftheinstitutionalimplementationteamanddefinitionofroles 27
43 Creation of institutional implementation plan 27
431 Selection of the Guideline to implement 28
432Identificationofbarriersandfacilitators 28
433Definitionofstrategiesanddisseminationactivities 30
434 Selection of implementation tools 31
435Definitionoftheincentiveplan 31
436Identificationofresourcesneededforimplementation 32
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS10
437 Preparation of the schedule of activities 32
438 Selection of evaluation and control mechanisms 32
44 Preparation of Baseline 33
45Practicalstepsindefiningtheinstitutionalimplementationplan 33
46 Tips for creating the implementation plan 36
5 PHASE 2 REALIZATION OF IMPLEMENTATION ACTIVITIES 37
6 PHASE 3 IMPLEMENTATION MONITORING AND FOLLOW-UP 41
61 Monitoring 42
62 Evaluation plan for implementing CPG 42
621 Components of the evaluation 43
63 Feedback and adjustments to the implementation plan 43
7 IMPLEMENTATION OF PATIENT GUIDELINES 45
ANNEXES 47
BIBLIOGRAPHY 67
1 Introduction
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Manual Developer Group
AuthorsAndreacutes Duarte OsorioThematic ExpertPontificia Universidad JaverianaPhysician and Surgeon Specialist in Family Medicine MSc in Clinical Epidemiology
Ana Marcela Torres AmayaThematic ExpertUniversidad Nacional de ColombiaPharmaceutical Chemist MSc in Clinical Epidemiology
Claudia Marcela VeacutelezThematic ExpertUniversidad de AntioquiaPhysician and surgeon Specialist in public health management and social security MSc in Clinical Science
Academic Director Rodrigo Pardo TurriagoUniversidad Nacional de ColombiaSurgeon Specialist in Clinical Neurology MSc in Clinical Epidemiology
Education TeamMichelle Corteacutes BarreacuteExpert in EducationPontificia Universidad JaverianaPhysician Masterrsquos in Education MSc in Clinical Epidemiology
Carlos Goacutemez RestrepoThematic ExpertPontificia Universidad JaverianaHospital Universitario San Ignacio Psychiatrist psychoanalyst psychiatrist liaison MSc in Clinical Epidemiology
Socialization TeamMariacutea del Pilar PastorExpert in Qualitative ResearchUniversidad de AntioquiaNurse MSc in Public Health PhD in Public Health Sciences
Vivian Marcela Molano SotoExpert in communicationUniversidad Nacional de Colombia Social communicator-Reporter MSc in Political Studies
Luz Helena Lugo AgudeloRepresentative CPG Developer GroupsUniversidad de AntioquiaMedical physiatrist MSc in Clinical Epidemiology
Vanesa Andreiacutena SeijasPilot Study SupportUniversidad de AntioquiaPhysician and surgeon
Leonardo Andreacutes Anchique Leal Systems EngineerAlianza Cinets website administrator
Fernando SuaacuterezExpert in Medical InformaticsUniversidad JaverianaGeneticist doctor MSc in Clinical Epidemiology and MSc in Bioinformatics and Medical Informatics
Administrative Support TeamClaudia Marcela VeacutelezManaging DirectorUniversidad de Antioquia
Paula Andrea Castro Garciacutea EconomistUniversidad de Antioquia
Claudia Espinosa Johnson Interpreter and Official Translator Member Colegio Colombiano de Traductores ndash CCTMinistry of Health and Social Protection
Participants in Manual Validation
Validation of Implementation Model
CPG Acute Coronary Syndrome
Juan Manuel SeniorInternist Hemodynamist CardiologistHospital San Vicente Fundacioacuten
Efraiacuten GoacutemezInternist CardiologistCliacutenica Shaio Sociedad Colombiana de Cardiologiacutea
Natalia Tamayo Internist CardiologistHospital San Vicente Fundacioacuten
Aacutengela DiacuteazAdministratorCliacutenica las Ameacutericas
Clara Ineacutes MejiacuteaPhysician auditCAPRECOM
Sebastiaacuten RuizRural doctorESE Copacabana
CPG Pregnancy
Joaquiacuten GoacutemezOB-GYN doctorUniversidad de Antioquia Director of Centro Nacer
Juan Guillermo LondontildeoOB-GYN doctorUniversidad de Antioquia NACER Group
Wilson MartiacutenezPhysicianMetrosalud
Luis Abel AldanaOB-GYN doctorHospital Marco Fidel Suaacuterez Bello and Cliacutenica Saludcoop Villa Nueva branch
Zaira RamiacuterezNurse Hospital Marco Fidel Suarez
Lina Mariacutea AriasPhysician Hospital Marco Fidel Suaacuterez de Bello
Moacutenica PatintildeoPhysician Metrosalud Unidad Hospitalaria de Manrique
Patricia ArbelaacuteezNurseMetrosalud Unidad Hospitalaria de Manrique
Arturo Cardona OspinaOB-GYN doctor Fetal Medicine SpecialistCliacutenica del Prado
Gloria CastantildeoNurse Cliacutenica del Prado
Johana ArangoNurse Cliacutenica del Prado
Manual Validation by Experts and System stakeholders
Ivaacuten Dariacuteo FloacuterezInstitute of Health Technology Assessment
Javier GuzmaacutenInstitute of Health Technology Assessment
Oscar Ariel Barragaacuten RiosQuality Office Ministry of Health and Social Protection
Indira Tatiana Caicedo ReveloQuality Office Ministry of Health and Social Protection
Hernando GaitaacutenHospital Universitario Universidad Nacional de Colombia
Jesuacutes EchavarriacuteaBogotaacute Health Office
Abel Ernesto Gonzaacutelez VeacutelezQuality Office Ministry of Health and Social Protection
Juan AlbornozCliacutenica de los Nogales
Lina Paola BonillaUniversidad Nacional de Colombia
Ana C FernaacutendezInstitute of Health Technology Assessment
Juan Manuel CorreaEPS Compensar
Jorge OrjuelaFundacioacuten Universidad Saacutenitas
Juan Pablo AlzateUniversidad Nacional de Colombia
Daniel Gonzalo EslavaUniversidad Javeriana
Pilot study ndash IPS SURA Medelliacuten
Clara Ximena SuaacuterezNational Audit Director of IPS Sura
Ana Catalina OchoaTechnical management analyst
Juan Carlos SuescuacutenEmergency Coordinator
Isabel Cristina FonnegraAuditor Basic IPS
Cesar Augusto CardonaInformation Analyst
Juan Esteban Holguiacuten Knowledge Management Analyst
Pilot study ndash Hospital de Fontiboacuten
Yidney Garciacutea RodriacuteguezManager
Nancy S Tabares RamiacuterezAssistant manager health services
Claudia P RoseroQuality leader
Liliana Castiblanco MososIntramural outpatient process leader
Marcela Saacutenchez CP and D Programs referent
Edgar FloacuterezAuditor
Diana NaranjoAuditor
Nancy ChacoacutenEpidemiologist
Clara Y PradaHospital Process Leader
Paola C GiraldoEmergency Process Leader
Pilot study ndash Hospital Universitario San Vicente Fundacioacuten
Fernando FortichInternist cardiologist
Yessica GiraldoGuideline group
Luz Marina QuicenoHead of Quality Assurance Office
Juan Fernando LondontildeoHead of Statistics Department
Yuli AgudeloResearch Unit Coordinator
Ministerio de Salud y Proteccioacuten Social - Colciencias 9
Content
1 INTRODUCTION 11
2 GLOSSARY 15
3 THE IMPLEMENTATION PROCESS IN THE COLOMBIAN SOCIAL SECURITY
SYSTEM IN HEALTH 19
31 National CPG Implementation Process 20
32 Scope and population under the CPG national implementation process 20
33 Roles for actors in the system 21
331 Ministry of Health and Social Protection (MSPS) 21
332 Institute for Health Technology Assessment (IETS) 21
333 Guideline Developer Groups (GDG) 22
334 Health Insurers (EPS or APB) 22
335 Health Service Provider Institutions 22
336 Higher Education Institutions 22
337ScientificSocieties 23
338 Associations of users and patients 23
339 Patients 23
4 PHASE 1 PLANNING AND CONSTRUCTION OF THE IMPLEMENTATION PLAN 25
41 CPG Adoption Policy 26
411 Steps for the adoption of CPG 26
42Establishmentoftheinstitutionalimplementationteamanddefinitionofroles 27
43 Creation of institutional implementation plan 27
431 Selection of the Guideline to implement 28
432Identificationofbarriersandfacilitators 28
433Definitionofstrategiesanddisseminationactivities 30
434 Selection of implementation tools 31
435Definitionoftheincentiveplan 31
436Identificationofresourcesneededforimplementation 32
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS10
437 Preparation of the schedule of activities 32
438 Selection of evaluation and control mechanisms 32
44 Preparation of Baseline 33
45Practicalstepsindefiningtheinstitutionalimplementationplan 33
46 Tips for creating the implementation plan 36
5 PHASE 2 REALIZATION OF IMPLEMENTATION ACTIVITIES 37
6 PHASE 3 IMPLEMENTATION MONITORING AND FOLLOW-UP 41
61 Monitoring 42
62 Evaluation plan for implementing CPG 42
621 Components of the evaluation 43
63 Feedback and adjustments to the implementation plan 43
7 IMPLEMENTATION OF PATIENT GUIDELINES 45
ANNEXES 47
BIBLIOGRAPHY 67
1 Introduction
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
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During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Participants in Manual Validation
Validation of Implementation Model
CPG Acute Coronary Syndrome
Juan Manuel SeniorInternist Hemodynamist CardiologistHospital San Vicente Fundacioacuten
Efraiacuten GoacutemezInternist CardiologistCliacutenica Shaio Sociedad Colombiana de Cardiologiacutea
Natalia Tamayo Internist CardiologistHospital San Vicente Fundacioacuten
Aacutengela DiacuteazAdministratorCliacutenica las Ameacutericas
Clara Ineacutes MejiacuteaPhysician auditCAPRECOM
Sebastiaacuten RuizRural doctorESE Copacabana
CPG Pregnancy
Joaquiacuten GoacutemezOB-GYN doctorUniversidad de Antioquia Director of Centro Nacer
Juan Guillermo LondontildeoOB-GYN doctorUniversidad de Antioquia NACER Group
Wilson MartiacutenezPhysicianMetrosalud
Luis Abel AldanaOB-GYN doctorHospital Marco Fidel Suaacuterez Bello and Cliacutenica Saludcoop Villa Nueva branch
Zaira RamiacuterezNurse Hospital Marco Fidel Suarez
Lina Mariacutea AriasPhysician Hospital Marco Fidel Suaacuterez de Bello
Moacutenica PatintildeoPhysician Metrosalud Unidad Hospitalaria de Manrique
Patricia ArbelaacuteezNurseMetrosalud Unidad Hospitalaria de Manrique
Arturo Cardona OspinaOB-GYN doctor Fetal Medicine SpecialistCliacutenica del Prado
Gloria CastantildeoNurse Cliacutenica del Prado
Johana ArangoNurse Cliacutenica del Prado
Manual Validation by Experts and System stakeholders
Ivaacuten Dariacuteo FloacuterezInstitute of Health Technology Assessment
Javier GuzmaacutenInstitute of Health Technology Assessment
Oscar Ariel Barragaacuten RiosQuality Office Ministry of Health and Social Protection
Indira Tatiana Caicedo ReveloQuality Office Ministry of Health and Social Protection
Hernando GaitaacutenHospital Universitario Universidad Nacional de Colombia
Jesuacutes EchavarriacuteaBogotaacute Health Office
Abel Ernesto Gonzaacutelez VeacutelezQuality Office Ministry of Health and Social Protection
Juan AlbornozCliacutenica de los Nogales
Lina Paola BonillaUniversidad Nacional de Colombia
Ana C FernaacutendezInstitute of Health Technology Assessment
Juan Manuel CorreaEPS Compensar
Jorge OrjuelaFundacioacuten Universidad Saacutenitas
Juan Pablo AlzateUniversidad Nacional de Colombia
Daniel Gonzalo EslavaUniversidad Javeriana
Pilot study ndash IPS SURA Medelliacuten
Clara Ximena SuaacuterezNational Audit Director of IPS Sura
Ana Catalina OchoaTechnical management analyst
Juan Carlos SuescuacutenEmergency Coordinator
Isabel Cristina FonnegraAuditor Basic IPS
Cesar Augusto CardonaInformation Analyst
Juan Esteban Holguiacuten Knowledge Management Analyst
Pilot study ndash Hospital de Fontiboacuten
Yidney Garciacutea RodriacuteguezManager
Nancy S Tabares RamiacuterezAssistant manager health services
Claudia P RoseroQuality leader
Liliana Castiblanco MososIntramural outpatient process leader
Marcela Saacutenchez CP and D Programs referent
Edgar FloacuterezAuditor
Diana NaranjoAuditor
Nancy ChacoacutenEpidemiologist
Clara Y PradaHospital Process Leader
Paola C GiraldoEmergency Process Leader
Pilot study ndash Hospital Universitario San Vicente Fundacioacuten
Fernando FortichInternist cardiologist
Yessica GiraldoGuideline group
Luz Marina QuicenoHead of Quality Assurance Office
Juan Fernando LondontildeoHead of Statistics Department
Yuli AgudeloResearch Unit Coordinator
Ministerio de Salud y Proteccioacuten Social - Colciencias 9
Content
1 INTRODUCTION 11
2 GLOSSARY 15
3 THE IMPLEMENTATION PROCESS IN THE COLOMBIAN SOCIAL SECURITY
SYSTEM IN HEALTH 19
31 National CPG Implementation Process 20
32 Scope and population under the CPG national implementation process 20
33 Roles for actors in the system 21
331 Ministry of Health and Social Protection (MSPS) 21
332 Institute for Health Technology Assessment (IETS) 21
333 Guideline Developer Groups (GDG) 22
334 Health Insurers (EPS or APB) 22
335 Health Service Provider Institutions 22
336 Higher Education Institutions 22
337ScientificSocieties 23
338 Associations of users and patients 23
339 Patients 23
4 PHASE 1 PLANNING AND CONSTRUCTION OF THE IMPLEMENTATION PLAN 25
41 CPG Adoption Policy 26
411 Steps for the adoption of CPG 26
42Establishmentoftheinstitutionalimplementationteamanddefinitionofroles 27
43 Creation of institutional implementation plan 27
431 Selection of the Guideline to implement 28
432Identificationofbarriersandfacilitators 28
433Definitionofstrategiesanddisseminationactivities 30
434 Selection of implementation tools 31
435Definitionoftheincentiveplan 31
436Identificationofresourcesneededforimplementation 32
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS10
437 Preparation of the schedule of activities 32
438 Selection of evaluation and control mechanisms 32
44 Preparation of Baseline 33
45Practicalstepsindefiningtheinstitutionalimplementationplan 33
46 Tips for creating the implementation plan 36
5 PHASE 2 REALIZATION OF IMPLEMENTATION ACTIVITIES 37
6 PHASE 3 IMPLEMENTATION MONITORING AND FOLLOW-UP 41
61 Monitoring 42
62 Evaluation plan for implementing CPG 42
621 Components of the evaluation 43
63 Feedback and adjustments to the implementation plan 43
7 IMPLEMENTATION OF PATIENT GUIDELINES 45
ANNEXES 47
BIBLIOGRAPHY 67
1 Introduction
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
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Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
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During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Pilot study ndash IPS SURA Medelliacuten
Clara Ximena SuaacuterezNational Audit Director of IPS Sura
Ana Catalina OchoaTechnical management analyst
Juan Carlos SuescuacutenEmergency Coordinator
Isabel Cristina FonnegraAuditor Basic IPS
Cesar Augusto CardonaInformation Analyst
Juan Esteban Holguiacuten Knowledge Management Analyst
Pilot study ndash Hospital de Fontiboacuten
Yidney Garciacutea RodriacuteguezManager
Nancy S Tabares RamiacuterezAssistant manager health services
Claudia P RoseroQuality leader
Liliana Castiblanco MososIntramural outpatient process leader
Marcela Saacutenchez CP and D Programs referent
Edgar FloacuterezAuditor
Diana NaranjoAuditor
Nancy ChacoacutenEpidemiologist
Clara Y PradaHospital Process Leader
Paola C GiraldoEmergency Process Leader
Pilot study ndash Hospital Universitario San Vicente Fundacioacuten
Fernando FortichInternist cardiologist
Yessica GiraldoGuideline group
Luz Marina QuicenoHead of Quality Assurance Office
Juan Fernando LondontildeoHead of Statistics Department
Yuli AgudeloResearch Unit Coordinator
Ministerio de Salud y Proteccioacuten Social - Colciencias 9
Content
1 INTRODUCTION 11
2 GLOSSARY 15
3 THE IMPLEMENTATION PROCESS IN THE COLOMBIAN SOCIAL SECURITY
SYSTEM IN HEALTH 19
31 National CPG Implementation Process 20
32 Scope and population under the CPG national implementation process 20
33 Roles for actors in the system 21
331 Ministry of Health and Social Protection (MSPS) 21
332 Institute for Health Technology Assessment (IETS) 21
333 Guideline Developer Groups (GDG) 22
334 Health Insurers (EPS or APB) 22
335 Health Service Provider Institutions 22
336 Higher Education Institutions 22
337ScientificSocieties 23
338 Associations of users and patients 23
339 Patients 23
4 PHASE 1 PLANNING AND CONSTRUCTION OF THE IMPLEMENTATION PLAN 25
41 CPG Adoption Policy 26
411 Steps for the adoption of CPG 26
42Establishmentoftheinstitutionalimplementationteamanddefinitionofroles 27
43 Creation of institutional implementation plan 27
431 Selection of the Guideline to implement 28
432Identificationofbarriersandfacilitators 28
433Definitionofstrategiesanddisseminationactivities 30
434 Selection of implementation tools 31
435Definitionoftheincentiveplan 31
436Identificationofresourcesneededforimplementation 32
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS10
437 Preparation of the schedule of activities 32
438 Selection of evaluation and control mechanisms 32
44 Preparation of Baseline 33
45Practicalstepsindefiningtheinstitutionalimplementationplan 33
46 Tips for creating the implementation plan 36
5 PHASE 2 REALIZATION OF IMPLEMENTATION ACTIVITIES 37
6 PHASE 3 IMPLEMENTATION MONITORING AND FOLLOW-UP 41
61 Monitoring 42
62 Evaluation plan for implementing CPG 42
621 Components of the evaluation 43
63 Feedback and adjustments to the implementation plan 43
7 IMPLEMENTATION OF PATIENT GUIDELINES 45
ANNEXES 47
BIBLIOGRAPHY 67
1 Introduction
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
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Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 9
Content
1 INTRODUCTION 11
2 GLOSSARY 15
3 THE IMPLEMENTATION PROCESS IN THE COLOMBIAN SOCIAL SECURITY
SYSTEM IN HEALTH 19
31 National CPG Implementation Process 20
32 Scope and population under the CPG national implementation process 20
33 Roles for actors in the system 21
331 Ministry of Health and Social Protection (MSPS) 21
332 Institute for Health Technology Assessment (IETS) 21
333 Guideline Developer Groups (GDG) 22
334 Health Insurers (EPS or APB) 22
335 Health Service Provider Institutions 22
336 Higher Education Institutions 22
337ScientificSocieties 23
338 Associations of users and patients 23
339 Patients 23
4 PHASE 1 PLANNING AND CONSTRUCTION OF THE IMPLEMENTATION PLAN 25
41 CPG Adoption Policy 26
411 Steps for the adoption of CPG 26
42Establishmentoftheinstitutionalimplementationteamanddefinitionofroles 27
43 Creation of institutional implementation plan 27
431 Selection of the Guideline to implement 28
432Identificationofbarriersandfacilitators 28
433Definitionofstrategiesanddisseminationactivities 30
434 Selection of implementation tools 31
435Definitionoftheincentiveplan 31
436Identificationofresourcesneededforimplementation 32
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS10
437 Preparation of the schedule of activities 32
438 Selection of evaluation and control mechanisms 32
44 Preparation of Baseline 33
45Practicalstepsindefiningtheinstitutionalimplementationplan 33
46 Tips for creating the implementation plan 36
5 PHASE 2 REALIZATION OF IMPLEMENTATION ACTIVITIES 37
6 PHASE 3 IMPLEMENTATION MONITORING AND FOLLOW-UP 41
61 Monitoring 42
62 Evaluation plan for implementing CPG 42
621 Components of the evaluation 43
63 Feedback and adjustments to the implementation plan 43
7 IMPLEMENTATION OF PATIENT GUIDELINES 45
ANNEXES 47
BIBLIOGRAPHY 67
1 Introduction
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 29
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS10
437 Preparation of the schedule of activities 32
438 Selection of evaluation and control mechanisms 32
44 Preparation of Baseline 33
45Practicalstepsindefiningtheinstitutionalimplementationplan 33
46 Tips for creating the implementation plan 36
5 PHASE 2 REALIZATION OF IMPLEMENTATION ACTIVITIES 37
6 PHASE 3 IMPLEMENTATION MONITORING AND FOLLOW-UP 41
61 Monitoring 42
62 Evaluation plan for implementing CPG 42
621 Components of the evaluation 43
63 Feedback and adjustments to the implementation plan 43
7 IMPLEMENTATION OF PATIENT GUIDELINES 45
ANNEXES 47
BIBLIOGRAPHY 67
1 Introduction
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
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Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
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Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
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Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
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Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
1 Introduction
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
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Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
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Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
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Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
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Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
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Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
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Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS12
Introduction
The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards
TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision
ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)
TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG
The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers
ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
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3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
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Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
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During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 13
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare
Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten
The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators
From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual
This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation
Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
2 Glossary
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
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Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
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Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
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Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
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Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS16
Glossary
AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)
AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)
AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)
Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)
Barriers Factors hindering dissemination and implementation (14)
CPG Clinical Practice Guideline
DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)
Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)
EAPBBenefitPlanAdministrators(acronyminSpanish)
EBM Evidence-Based Medicine
EPS Health Promoting Entities (acronym in Spanish)
Facilitators Factors promoting dissemination and implementation (14)
GDG Guideline Development Groups
IETS Institute for Health Technology Assessment (acronym in Spanish)
ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)
Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)
Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)
Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
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Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
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During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 17
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)
MSPS Ministry of Health and Social Protection (acronym in Spanish)
NICE National Institute for Health and Care Excellence
Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)
Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)
Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)
Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)
SGSSS General System of Social Security in Health (acronym in Spanish)
SIGN Scottish Intercollegiate Guidelines Network
SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 29
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 31
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
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Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
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Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
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Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
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Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
3 The implementation process in the Colombian Social Security
System in Health
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS20
The implementation process in the Colombian Social Security System in Health
The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public
The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation
31 National CPG Implementation Process
Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon
theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto
ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof
theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)
bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG
32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 29
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 31
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
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Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
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Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 21
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups
33 Roles for actors in the system
The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations
331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated
intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin
thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the
processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently
findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation
of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for
monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth
Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health
informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them
bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available
332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer
groups to facilitate their implementability and development of the implementation plans
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS22
bull To form regional nodes to facilitate the adoption and implementation process at different levels of care
bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG
implementationsbull To participate in institutional adjustment processes directed toward successful CPG
implementationsbull To design or accompany the design and conduct of studies to generate evidence about best
practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the
Ministry of Health and Social Protection
333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and
finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies
thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and
strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG
334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG
implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective
CPG implementations
335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation
processesbull To check and adjust the IPS information systems according to the implementation standards
and indicators proposed in the CPGs
336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human
resources in health and in the relevant subject areas discuss the contents and CPGrecommendations
bull To design and implement continuing education programs in CPG for graduates and health institutions
The implementation process in the Colombian Social Security System in Health
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 29
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 31
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 33
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
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Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
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Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
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Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
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Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
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Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
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Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 23
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes
bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs
337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer
groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs
bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry
of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating
of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism
ofself-regulationandqualityassurance
338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation
339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 29
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
4 Phase 1 planningand construction of the
implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
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433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
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Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS26
Phase1planningandconstructionoftheimplementationplan
TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline
41 CPG Adoption Policy
The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess
When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals
InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)
Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)
The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol
411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation
processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
Ministerio de Salud y Proteccioacuten Social - Colciencias 39
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 27
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas
42 Creationoftheinstitutionalimplementationteamanddefinitionofroles
An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem
Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand
coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities
bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients
The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan
43 Elaboration of the institutional implementation plan
The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned
Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 29
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 31
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 33
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 35
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
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Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
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Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
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3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
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Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS28
Here are the steps for the development of the institutional implementation plan
431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation
Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented
432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)
Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry
TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)
bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext
bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 29
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 31
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 33
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
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Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
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Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
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Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 29
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults
bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured
bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess
bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess
The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable
Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples
Innovation
Feasibility Credibility Accessibility Attraction
TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification
Individual professional
Awareness Knowledge Attitude Motivation for changeBehavior routines
Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered
Patient
Knowledge Skills Attitude Adherence
Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation
Social Context
Colleaguesrsquo opinionNetwork CultureCollaboration Leadership
Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions
Organizational Context
Personal careprocessesCapacities Resources Structures
Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities
Political and Economic Context
Financial arrange-mentsRegulations Policies
Resource allocation does not consider the implementation of certain recommendations
Implementation Process Implementation and assessment plan
No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy
Quality of the Guideline Quality of the report No inclusion of a simplifiedversion
The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language
AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 31
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 33
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
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Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
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Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
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Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS30
433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider
Table 2 Strategies for dissemination of CPGStrategy Definition
Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)
Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)
Electronic systems to support decision making
Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)
Only distributiondissemination
ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users
Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)
Individualized educa-tional visits
Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)
Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)
Contents of the guide
Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied
Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG
Administrative Inter-ventions
They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)
Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation
Distribution of educa-tionalmaterials
PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow
Multiple interventions It consists of combining multiple strategies
Interventions on organizations
Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 31
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 33
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 35
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
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Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
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Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
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3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
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Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 31
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Strategy Definition
Specifictopatients Activitiesaimedspecificallyatpatients
Regulatory interven-tions
Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)
Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)
Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)
Development of guideline in consen-sus with user
Development of the guideline in consensus with the end user of the same
Adapted from Systematic review of CPG implementation strategies (5)
434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination
TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco
435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators
Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)
bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 33
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 35
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
Ministerio de Salud y Proteccioacuten Social - Colciencias 39
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS32
bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance
bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)
bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient
436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified
437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation
438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact
Table 3 Indicators of the implementation processAssociated
factorsType of indi-
cator Effectiveness Impact
Provision of health services
StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care
Increased coverage in rural areas andor vulnerable population
Process
Number of patients treated according to the CPG recommendations
Effective coverage with the CPG recommendations
Number of CPG recommendations included in the purchase and delivery of health services
Reduction of pocket spending for new health interventions
Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition
Reduced mortality or number of complications by health condition
Financing
Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation
Budget Impact of health care as recommended by CPG
Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG
Price regulation of purchase and sale of health interventions
Results Financingofspecificinterventionsbyclinicalprac-tice guideline
Reduction of pocket spending for new health interventions
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 35
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
Ministerio de Salud y Proteccioacuten Social - Colciencias 39
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
Ministerio de Salud y Proteccioacuten Social - Colciencias 43
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
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- Bibliografiacutea
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- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Associated factors
Type of indi-cator Effectiveness Impact
Human re-sources
Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery
Reduced mortality or number of complications by health condition
Process Number of graduate health professionals and in trainingtrainedinCPG
Effective coverage with the CPG recommendations
Results Number of health professionals who provide health services as recommended by the CPG
Reduced mortality or number of complications by health condition
Information Systems
Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system
Process Number of recommendations of each CPG included in information system
Regulationofcostsandqualityofhealth interventions
Results Number of institutions with CPGs incorporated into computerized medical history
Makingefficientclinicalandad-ministrative decision
AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)
44 Preparation of Baseline
Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution
Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability
45Practicalstepsindefiningtheinstitutionalimplementationplan
bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS
bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)
bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
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Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
Ministerio de Salud y Proteccioacuten Social - Colciencias 39
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
Ministerio de Salud y Proteccioacuten Social - Colciencias 43
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
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Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
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Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
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Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS34
implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement
bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)
bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose
bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of
indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations
46 Tips for creating the implementation plan (27)
The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof
implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the
planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss
them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects
bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext
bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution
bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence
bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical
pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the
strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation
bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS
Phase1planningandconstructionoftheimplementationplan
Ministerio de Salud y Proteccioacuten Social - Colciencias 35
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
Ministerio de Salud y Proteccioacuten Social - Colciencias 39
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
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3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
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Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
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During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 35
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)
bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area
bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons
bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
Ministerio de Salud y Proteccioacuten Social - Colciencias 39
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
Ministerio de Salud y Proteccioacuten Social - Colciencias 43
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
5 Phase 2 realization ofimplementation activities
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
Ministerio de Salud y Proteccioacuten Social - Colciencias 39
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
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Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS38
Phase2realizationofimplementationactivities
This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers
By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork
This team should have available
bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented
bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines
bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them
bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance
Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities
CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients
The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment
Ministerio de Salud y Proteccioacuten Social - Colciencias 39
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
Ministerio de Salud y Proteccioacuten Social - Colciencias 43
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 39
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects
Table 4 Summary of interventions to overcome barriers
Interventions on profes-sionals
- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media
Financial interventions - Professional or institutional incentives - Incentives for patients
Organizational interven-tions
These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural
Regulatory interventions
Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation
Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg
The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings
bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done
bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement
bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore
effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith
relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior
changeandefficiency
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
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Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
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3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
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Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
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Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
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During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
6 Phase 3 implementation monitoring and follow-up
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
Ministerio de Salud y Proteccioacuten Social - Colciencias 43
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS42
Phase3implementationmonitoringandfollow-up
OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical
In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe
effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies
bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange
61 Monitoring
Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after
EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible
Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations
62 Evaluation plan for implementing CPG
When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor
acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic
criteria based on audits and routine monitoring
Ministerio de Salud y Proteccioacuten Social - Colciencias 43
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
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- 61 Monitoring
- 62 Evaluation plan for implementing CPG
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- 621 Components of the evaluation
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- 63 Feedback and adjustments to the implementation plan
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- 7 Implementation ofpatient guidelines
- Annexes
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- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
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- Bibliografiacutea
- Implementation guide 1pdf
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- Bibliografiacutea
- _GoBack
- 1 Introduction
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- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
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- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
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- 4 Phase 1 planning
- and construction of the implementation plan
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- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 43
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof
theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external
organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe
performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent
FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)
WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified
621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process
63 Feedback and adjustments to the implementation plan
Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
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Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
7 Implementation ofpatient guidelines
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS46
Implementation of patient guidelines
The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations
The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies
It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result
bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)
bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents
videoconferences
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Annexes
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS48
Annex 1Comprehensive implementation model of clinical practice guidelines
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
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Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 49
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Date
Institution
Name of the Clinical Practice Guideline
Reason for the choice of the guideline
Relationship to existing policies or clinical practice guidelines implemented in the institution
Members of the institutional implementation teamName Position in institution Office Role
Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group
Annex 2Institutional implementation plan
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
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Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS50
Annex 2 Institutional implementation plan
Number Recommendation
1
2
3
4
5
6
7
8
Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Recommendation
Barriers to implementation Facilitators
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
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Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 51
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)
Review relevant section of the manual and identify implementation strategies which can be applied in the institution
Steps for adoption of the recommendations Identify the activities that should be developed in the IPS
Activity (data collection training development of forms acquisitions etc) Responsible Start date End date
Educational and dissemination strategies
Who are educationalstrategies aimed at
What informationis needed When do they need it Who will provide
the information
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS52
Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)
Approval by the appropriate level of managementName Approval Date of application Date of approval
IndicatorsMeasurement Date
Indicator Numerator Denominator Source Number
Annex 2 Institutional implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 53
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 3Identifier of barriers to implementation
Barriers Observation Present Strategy to overcome
Concerning the CPG
Evidenceinsufficienttosupportallrecommendations YES NO
Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO
Thepublishingformslimittheirfrequentconsultation YES NO
Final recommendations may present ambiguity in their interpretation by general practitioners YES NO
The references are not easily accessible to the public user of the CPG YES NO
Con
cern
ing
prof
essi
onal
s
Ignorance of the existence of the guidance and evidence based med-icine YES NO
Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace
YES NO
Continuous training and updating in the hands of the pharmaceutical industry YES NO
Resistance to change and fear of facing medical-legal problems YES NO
Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO
Lack of peer support and poor teamwork YES NO
Perception that CPG does not apply to most patients or in all IPS YES NO
Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO
Concerning social con-text
Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS54
Annex3Identifierofbarrierstoimplementation
Con
cern
ing
the
econ
omic
and
org
aniz
atio
nal c
onte
xt
Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO
The shortcomings of the enabling system and control of health care providers (IPS) YES NO
The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices
YES NO
AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis
YES NO
Improper operation of the information system YES NO
Limited leadership of those responsible for the IPS YES NO
IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO
Few IPS accredited or in accreditation process YES NO
Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO
Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO
Ignorance of the costs and funding sources for the CPG implemen-tations YES NO
Other Bar-riers
YES NO
YES NO
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 55
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Annex 4Tools and resources for implementation
Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions
CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows
National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco
International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk
41 CPG Versions and forms for SGSSS in Colombia
To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic
InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG
42 Stages of Change Model
Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS56
Annex 4 Tools and resources for implementation
fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance
Theory of stages of change adapted to the process of CPG use in clinical practice of health professional
Stage Definition Strategies for change Priority educational activities to promote change
Pre-consideration
(Referring to as-sertion A of the CPG Survey)
The health profes-sional has no inten-tion to implement the CPGs in the clinical practice
Identify the reasons why the health pro-fessional has no intention to implement the CPG
Show the importance of implementing CPGs in clinical practice
Provide information about the risks and benefitsoftheapplicationofCPG
We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation
minus Knowbeliefsvaluesandopinionsofhealth professional on CPG
minus Identify barriers to implementation and propose solutions
Consideration
(Referring to as-sertion B of the CPG Survey)
The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture
Provide information on the benefits ofCPG implementation
Promote the implementation of a plan of action
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for clinical case
Preparation
(Referring to as-sertion C of the CPG Survey)
The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it
Assist the health professional in devel-opingaspecificactionplan
Present the CPG recommendations and how to apply them in clinical prac-tice
We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel
minus Develop a group action plan for CPG implementation
minus Establish an individual commitment to implementing the CPG recommen-dations
minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 57
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Stage Definition Strategies for change Priority educational activities to promote change
Action
(Referring to as-sertion D of the CPG Survey)
The health profes-sional has been using the CPG in the clinical prac-tice less than six months
To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice
Provide activities to strengthen the CPG implementation
We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations
minus Choose the appropriate course of action for the clinical case
minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions
minus ReflectontheprocessofCPGimple-mentation
Maintenance
(Referring to as-sertion E of the CPG Survey)
The health profes-sional has used the CPG in the clinical practice for over six months
Provide feedback to the health pro-fessional about changes to the clinical practice
Provide activities for strengthening and update
We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation
minus Present the results of the implemen-tation plan
minus Reflectontheresultsoftheindica-tors
43 Learning Strategies
The main learning strategies that can be selected for the educational activities in implementation programsare
1 Strategies for reproduction of knowledge
minus Repeat the text orally
minus Create analogies and metaphors
minus Use mnemonics
minus Summarize the text
minus Create mental images
minus Replyandcreatequestions
minus Paraphrase
minus Teach others
minus Associatetheknowledgewithotherspreviouslyacquired
minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge
minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS58
3 Strategies for self-evaluation and self-regula-tion
Planning Strategies minus DefinelearninggoalsinCPG
Monitoring strategy minus To assess the understanding of the content of the CPG
minus Identify strengths and weaknesses in the CPG
minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG
Executive control strategy
minus Devise corrective if indicators or targets were not achieved
Strategies associat-ed with motivation
minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)
Evaluate the expec-tation of successfailure
minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG
Assess the emo-tional and attitudi-nal factors
minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG
4 Management of contextual factors
Time Management minus Assess the timing and planning for the study and CPG implementation
Physical environ-ment for learning
minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study
Definesupportstrategies
minus Ask others for help
minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired
5 Management of educational re-sources
minus Use the Ministry of Health and Social Protection platform
minus Use the full CPG as a consultation document
minus Use the CPG for Health Professionals
minus Use Guideline for Patients and Families
minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG
minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG
minus Askconstantquestionsabouttheimprovementofcareforourpatients
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 59
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
44 Teaching techniques to support implementation
Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows
Teaching technique Objectives and process Resources Advantages Recommendations
Confe-renceLecture
Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people
minus Room
minus Boardflip-chart or overhead projector
minus Sound
minus PowerPoint Presentation
minus Ideallyase-nior lecturer on the sub-jectopinionleader
It is an inex-pensive way to commun ica te informationSuitable for large groups of people
Present the information in an orderly manner and emphasize the most im-portant aspects
Use visual aids to capture the audi-encersquos attention and facilitate learn-ing
Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information
Use examples and case studies to keep the concentration of the audi-ence
Encourage audience participation throughquestionstoavoidadoptingapassive attitude
Case study
(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)
The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient
Theactivityhas3phases
Individual assessment of patient management case
Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling
Development of a management proposal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (writing of the caseCPG)
Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning
Select a real case that has been treat-edat the institution inorder tohaveaccess to full information
Choose a case that represents a sit-uation of complex decision making addressed b CPG
Avoid mentioning the names of the people who handled the case
From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient
Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS60
Case study
(cases fo-cused on creating proposals for deci-sion-mak-ing)
The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management
Theactivityhas3phases
minus Individual assessment of the case and proposed manage-ment options
minus Analysis and discussion in group of proposed manage-ment options
minus Develop a management pro-posal based on the CPG rec-ommendations
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Ideallyanexpert opinion leader to lead the activity
minus Educational materials (caseCPG)
Encourages critical analysis of real clinical situations
Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion
Promotes active participationwhich fosters meaningful learning
Choose a case that represents a situation of complex decision making addressed by CPG
Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient
Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case
Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management
Prob-lem-Based Learning
A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives
The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study
Theactivityhas4phases
minus Presentation of the problem
minus Identificationoflearningneeds
minus Search and ownership of infor-mation
minus Resolution of the problem and identificationofnewproblems
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Availability of bibliographic resources
minus Ideallyhavea computer with internet access
It allows partic-ipants to make a diagnosis of their own learn-ing needs
Promotes active participationwhich promotes meaningful learning
It stimulates self-learning
Encourages critical analysis of real clinical situations
Fosters the development of interpersonal skills
Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed
Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work
Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills
At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 61
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Educational workshop
Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct
The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting
minus Room that allows small group work
minus Board or flipcharttorecord the contributions of the partici-pants
minus Paper or computer to prepare the finaldocu-ment
Stimulates the expression of beliefsvaluesopinions and experiences of the participants
Promotes dia-logue among participants
Fosters the development of interpersonal skills
Allows group development of afinalproduct
Preparethesubjectclinicalcaseorguidingquestionoftheworkshop
Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic
Promote the participation of all at-tendees
Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument
Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument
Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations
Theeventhas4phases
Organization of the simulated clin-ical case or scenario
Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario
Interaction with the situation par-ticipants to act or make decisions
-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants
minus Physical space suit-able for simu-lation
minus Peoplema-terials and equipmentre-quiredforthesimulation
Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions
Avoids the risks of training in real clinical settings
Encourages the development of behaviors and attitudes
Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants
Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment
After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance
Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation
45 Educational strategy for the implementation of CPG
There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows
First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS62
Objectivesbull Present the CPG to health personnel
- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)
- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health
personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health
personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice
Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly
During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)
After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium
Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 63
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof
the case and the CPG recommendations
Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting
During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)
Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation
Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible
solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG
recommendations in their daily clinical practice
Before the activitySummon the people involved in the process of CPG implementation
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS64
During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective
After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium
Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop
Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date
- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG
bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan
Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators
During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators
Annex 4 Tools and resources for implementation
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 65
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)
After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 67
1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press
2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20
3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645
4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838
5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion
6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30
7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de
Bibliography
Seguridad Social en Salud Colombiano BogotaacuteColombia 2010
8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013
9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304
10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013
11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009
12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003
13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416
14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS68
Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)
15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794
16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98
17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76
18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227
19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009
20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523
21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156
22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama
CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones
23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones
24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02
25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36
26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856
27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2
28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30
29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto
Bibliography
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
Ministerio de Salud y Proteccioacuten Social - Colciencias 69
Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia
EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008
30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar
31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-
for evidence-based clinical practice guidelines in health institutions in colombia
Implementation manual
gpcminsaludgovco
- 1 Introduction
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
-
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning and construction of the implementation plan
-
- 41 CPG Adoption Policy
-
- 411Steps for the adoption of CPG
-
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
-
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
- 437 Preparation of the schedule of activities
- 438 Selection of evaluation and control mechanisms
-
- 44 Preparation of Baseline
- 45 Practical steps in defining the institutional implementation plan
- 46 Tips for creating the implementation plan (27)
-
- 5 Phase 2 realization ofimplementation activities
- 6 Phase 3 implementation monitoring and follow-up
-
- 61 Monitoring
- 62 Evaluation plan for implementing CPG
-
- 621 Components of the evaluation
-
- 63 Feedback and adjustments to the implementation plan
-
- 7 Implementation ofpatient guidelines
- Annexes
-
- Annex 1Comprehensive implementation model ofclinical practice guidelines
- Annex 2Institutional implementation plan
- Annex 3Identifier of barriers to implementation
- Annex 4Tools and resources for implementation
-
- Bibliografiacutea
- Implementation guide 1pdf
-
- Bibliografiacutea
- _GoBack
- 1 Introduction
-
- 2 Glossary
- 3 The implementation process in the Colombian Social Security System in Health
-
- 31 National CPG Implementation Process
- 32 Scope and population under the CPG national implementation process
- 33 Roles for actors in the system
- 331Ministry of Health and Social Protection (MSPS)
- 332Institute for Health Technology Assessment (IETS)
- 333Guideline Developer Groups (GDG)
- 334Health Insurers (EPS or APB)
- 335Health Service Provider Institutions
- 336Higher Education Institutions
- 337Scientific Societies
- 338Associations of users and patients
- 339Patients
-
- 4 Phase 1 planning
- and construction of the implementation plan
-
- 41 CPG Adoption Policy
- 411Steps for the adoption of CPG
- 42 Establishment of the institutional implementation team and definition of roles
- 43 Creation of institutional implementation plan
- 431 Selection of the Guideline to implement
- 432 Identification of barriers and facilitators
- 433 Definition of strategies and dissemination activities
- 434 Selection of implementation tools
- 435 Definition of the incentive plan
- 436 Identification of resources needed for implementation
-