National Guidelines Update National Guidelines Update Process: Key StepsProcess: Key Steps

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ObjectivesObjectives

• Identify guideline components• Share best practices in the guidelines

development and dissemination

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What are Guidelines ?What are Guidelines ?

Guidelines may include several components:

• Service delivery policies

• Service delivery standards

• Clinical guidelines and protocols

• Clinical management plans

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Why Develop National Guidelines ?Why Develop National Guidelines ?

Guidelines are key to improving access to high quality service delivery:

• Provide the foundation on which high quality services can be built or strengthened

• Reduce medical and access barriers

• Standardize provider practices

• Guide the content for inservice training and preservice education programs

• Guide supervisory and management systems

• Provide standards for monitoring and evaluating quality of care

5“MAQ: From Guidelines…to Action Conference”, May 1998

Steps in the Guidelines Process

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• Review data

• Collect existing documentation– national level– service delivery points

• Conduct needs assessment− include compliance

issues

Step 1: Establish Need

Indonesia Example• Variety of service

delivery guidelines− national

government− professional

organizations− project specific

documents− NGO materials

• Confusion among providers and managers

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• Solicit opinion of all stakeholders

• Solicit policy level support through strategic and frequent meetings with senior officials

• Prepare a plan and obtain commitment and approval to participate in plan

• Form a broad-based committee to steer process

Step 2: Ensure Broad Scope andCommitment

Indonesia Example

• STARH program identified key/influential stakeholder: YBP-NGO led by providers

• Convinced and empowered YBP to lead the service delivery guidelines development

• Provided resources− technical assistance− implementation− printing and

dissemination

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Step 2: Ensure Broad Scope andCommitment

Expert Committee inTurkey’s NationalGuidelines Development

Representatives of: • Ministry of Health• University • Service providers,

trainers, and their professional associations

• Local NGOs, FP associations

• UNFPA and USAID cooperating agencies

Expert Committee inIndonesia’s National FPService Delivery GuidelinesDevelopmentRepresentatives of: • Ministry of Health• Nat’l FP Coordinating

Board• Service providers, clinical

trainers, and their professional associations

• Medical & Midwifery faculty representatives

• Local NGOs, FP associations

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• Get input from all levels of the health service system pyramid

• Identify practices that are positive

• Conduct broad discourse on proposed guidelines

• Utilize national and international resources

Step 3: Develop Outline and Content

Indonesia Example

• Identify the target audience− providers at the

PusKesMas• Need to know clear,

updated Information− clinical − program

• Compact and affordable to be in the hands of all providers

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Step 3: Technical Resources

• WHO 2008 Eligibility Criteria

• WHO 2008 Selected Practices Recommendations

• Family Planning Global Handbook for Providers, 2007

• JHPIEGO Infection Prevention reference manual, 2004

• CPI guidance documents

Reference documents and resources guide the formulation of up-to-date guidelines:

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Step 4: Testing and RevisingStep 4: Testing and Revising

• Field testing done by a variety of providers

• Review for technical accuracy, user-friendliness, internal consistency

• Revisions should reflect client perspectives

• Review and revise with sanctioning authorities

Indonesia Example

• Feedback from− editors and

stakeholders- internal − NGOs and CAs

including UNFPA and WHO - external

− providers during Contraceptive Technology Update workshops

• Iterative review process

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Step 5: Preparing For DisseminationStep 5: Preparing For Dissemination

• Host country plans strategy and ensure adequate funding

• Formulate clear and flexible workplan

• Plan to use a wide variety of formats

• Go beyond distribution to ensure application in plan

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• Involve and reach all organizations concerned

• Plan series of workshops for different groups at different levels of service

• Issue an official letter validating the guidelines and use other opportunities to broadcast them officially

• Promote using creative mechanisms

Step 6: Dissemination StrategiesStep 6: Dissemination Strategies for for SuccessSuccess

Indonesia Example• Secure documented

official endorsements• Plan national launch in a

high profile event• Print starter copies for

distribution • Develop target

distribution list• Encourage use of the

material during training of providers

• Encourage use in supervision tools

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• Radio dramas• Dissemination workshops• Flyers• Internet• Hotlines• Audio cassettes• Posters and logos• Modeling by respected colleagues

Step 6: Dissemination and Step 6: Dissemination and Promotion StrategiesPromotion Strategies

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Step 7: Hit All the TargetsStep 7: Hit All the Targets

• Service delivery points

• Training programs

• Education programs

• Program planning• Community linkages

Source: Population Reports, Series J, Number 47, 1998.

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vs.

• Pregnancy safely ruled out by checklist in 90% of women typically sent home if not menstruating at a time of their visit

• Of those pregnancies ruled out by checklist only <0.5% where found pregnant by pregnancy test

Dipstick Pregnancy Test

Pregnancy Checklist

Step 7:Kenya Service Delivery Example

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Use positive, team- based approaches that make providers partners in promoting guidelines use and solving problems in their application!

Source: Population Reports, Series J, Number 47, 1998.

Step 8: Ownership EncouragesAdherence

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• Identify focus of responsibility for adherence and authority for ensuring it

• Ensure orientation and training around guidelines

• Look beyond the guidelines for causes of lack of adherence

Step 8: Build Adherence Into The System

Indonesia Example

• Dissemination activities led by team of national & local providers

• Shared results of on- going survey on compliance issues during dissemination

• Invited both providers and program managers

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Ecuador Sustainability StudyEcuador Sustainability Study

• Before: CEMOPLAF policy on IUDs required 4 revisits

• Study: on impact of reducing mandatory IUD follow-up visits to 1

• Results: actual revisits reduced 36% while only detecting 7% less serious medical complications

• Savings: $23,000 for clients, $10,000 for CEMOPLAF, 1800 provider hours annually

Step 8: Explore Reasons for Non-Adherence

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• Send periodic content pieces reinforcing guidelines--especially problem-solving tips and solutions found by practicing colleagues

• Develop/use job aids and coaching

Step 8: Provide The Tools for Adherence

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Methods to monitor compliance:

• Self assessment (with checklist)• Supervision and training • Follow-up• Peer review• Medical monitoring• Record review• Client surveys• Action research

Step 8: Monitor Compliance

Source: Population Reports, Series J, Number 47, 1998.

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• Plan for periodic review early in process

• Provide content and program updates to steering committee

• Plan for host country self-reliance for guidelines revisions and updates

• Establish mechanisms for providing technical professionals in the field with up-to-date scientific information

Step 9: Plan for Updates

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• Evaluate the integration of guidelines in daily service provision practices

• Evaluate the impact on access to and quality of care, and accordingly take initiatives to strengthen these

• Apply results of evaluation to new initiatives to strengthen quality and access

• Integrate indicators into existing data collection systems

Step 10: Evaluate

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REFERENCEREFERENCE

• STEPS IN GUIDELINES PROCESS, 1998 MAQ EXCHANGE POWERPOINT PRESENTATIONS

• BP3K GUIDELINES DEVELOPMENT PRESENTATION, 2002