RECENT ADVANCES
How to implement change in clinical practice

https://doi.org/10.1016/S1526-0542(03)00092-7Get rights and content

Abstract

Changing clinical practice is a major challenge. It is not acceptable simply to send out a new clinical guideline or care pathway and expect there to be a change in practice. This paper addresses the problems associated with the development of a clinical guideline and sets out a clear strategy for dissemination, implementation and evaluation in a way that should promote the successful change of practice. The first section examines the development of the guideline. National or international guidelines may well exist but local adaptation and refinement of those guidelines are required, along with a local summary document. Valid, reproducible, evidence-based, clear, logical, easily accessible guidelines need to be available after widespread local, multi-professional consultation. Second, prior to dissemination, there needs to be promotion among all the health professionals and families involved with the change in practice. Appropriate educational and multi-disciplinary interventions, highlighting and informing in workshops and preparing people for the changes are recommended. Recognising the barriers to implementation and change and addressing these locally is important. Once the guideline has been disseminated and implemented and the change in practice has occurred, full evaluation and ongoing audit of the changes in practice are required to sustain the changes.

Section snippets

INTRODUCTION

There are many potential barriers to promoting change within an organisation.1., 2. Developing and using guidelines and care pathways are ways to promote evidence-based, safe, cost-effective clinical care and change clinical practice.3., 4., 5.

Improving knowledge does not necessarily alter behaviour. Whether we are discussing patients with diabetes, educating families and children with asthma or developing a teaching programme for junior doctors, the alteration of behaviour to improve outcome

INTERNAL FACTORS

It is worthwhile considering the internal factors and barriers associated with a guideline in two sections: the pre-development stage, examining the need for the change in practice, and then the development stage, in which a valid guideline is developed from national recommendations or new research evidence and refined for local use.

EXTERNAL FACTORS

Once the guideline or care pathway has been developed and accepted by the key local players, a clear strategy of implementation is required. It would seem appropriate to develop the implementation strategy in two sections: first, a period of time before the launch of the guideline or pathway in order to prepare for the change in practice;13 second, the launch of the guidelines and the change in practice, considering the strategies to sustain, and ensuring that the change in practice continues

CONCLUSION

Change in clinical practice requires time, resources and planning. Guidelines or care pathways will aid the change in clinical practice but clear, well-defined strategies are required when considering development, dissemination, implementation and evaluation. There may be many reasons why any attempt to change practice will fail (Table 1) and if these issues are addressed prior to the process, it is likely that the change will be successful. It is no longer acceptable for a guideline simply to

PRACTICE POINTS

Factors to consider in the development and implementation of a guideline or clinical care pathway:

  • Internal factors – developing a valid guideline or care pathway

    • (1)

      Pre-development

      • Is there a gap between research and practice?

      • What is the prevalence of the disease in the local community?

    • (2)

      Development of the guideline

      • Is there a national evidence-based guideline already available for local adaptation?

      • Has there been wide, local, multi-disciplinary consultation before the pathway or guideline is

RESEARCH DIRECTIONS

  • As guidelines and clinical pathways proliferate, further research needs to be focused on the impact that these guidelines have on patients and service costs.

  • Surprisingly little is known about the effectiveness and cost-effectiveness of interventions that aim to change practice or the delivery of health care.23

  • Studies examining patient outcome and satisfaction with changes in practice, along with cost to the health service and families, need to augment studies addressing the safety and efficacy

References (37)

  • C.L Emerman et al.

    Survey of asthma practice among emergency physicians

    Chest

    (1996)
  • A.M Leversha et al.

    Costs and effectiveness of spacer versus nebulizer in young children with moderate to severe asthma

    J. Pediatr.

    (2000)
  • B Haynes et al.

    Barriers and bridges to evidence based clinical practice

    BMJ

    (1998)
  • A Haines et al.

    Making better use of research findings

    BMJ

    (1998)
  • S.H Woolf et al.

    Clinical practice guidelines: the potential benefits, limitations and harms of recommending how to care for patients

    BMJ

    (1999)
  • K.B Johnson et al.

    Effectiveness of a clinical pathway for inpatient asthma management

    Pediatrics

    (2000)
  • R Chin et al.

    Effectiveness of a croup clinical pathway in the management of children with croup presenting to an emergency department

    J. Paed. Child Health

    (2002)
  • Global Initiative for Asthma. GINA Guidelines, 2002. Global Strategy for Asthma Management and Prevention. Bethesda,...
  • National Asthma Campaign Australia. Asthma Management Handbook 2002....
  • British Thoracic Society/Scottish Intercollegiate Guidelines Network. British Guideline on the management of asthma....
  • J.A Finkelstein et al.

    Self reported practices for children with asthma: are national guidelines followed?

    Pediatrics

    (2000)
  • M Haby et al.

    Asthma in children: gaps between current management and best practice

    J. Paediatr. Child Health

    (2002)
  • M.D Cabana et al.

    Reasons for pediatrician non-adherence to asthma guidelines

    Arch. Pediatr. Adolesc. Med.

    (2001)
  • C.V.E Powell et al.

    Successful implementation of spacer treatment guideline for acute asthma

    Arch. Dis. Child

    (2001)
  • M Gazarian et al.

    Evaluating the effectiveness of evidence-based guidelines for the use of spacer devices in children with acute asthma

    Med. J. Austr.

    (2001)
  • Scottish Intercollegiate Guidelines Network. SIGN 50: A Guidelines Developers’ Handbook. Edinburgh: SIGN,...
  • Royal College of Paediatrics and Child Health. Standards for the Development of Clinical Guidelines in Paediatrics and...
  • I Amirav et al.

    Metered dose inhaler accessory devices in acute asthma: a literature review

    Arch. Dis. Adolesc. Med.

    (1997)
  • Cited by (33)

    • Perioperative antimicrobial prophylaxis in pediatric patients in Greece: Compliance with guidelines and impact of an educational intervention

      2016, Journal of Pediatric Surgery
      Citation Excerpt :

      The difference in the rates of compliance among these types of procedures could be potentially attributed to surgeons choosing to continue antimicrobial prophylaxis until the removal of urinary catheters (although it is not recommended by relevant guidelines) [5], to the high risk of SSIs associated with the contaminated procedures, or to the small sample size in those subgroups. International PAP guidelines exist but local adaptation and refinement of those guidelines are required [17,18]. This study revealed that an appropriate educational and multidisciplinary intervention, which highlighted and informed the pediatric surgeons about the needed changes in clinical practice was an effective strategy.

    • Barriers to Metered-dose Inhaler/spacer Use in Canadian Pediatric Emergency Departments: A National Survey

      2007, Academic Emergency Medicine
      Citation Excerpt :

      This likely speaks to the unique practice environment of the PED, where a significant change to the ED practice culture requires considerable effort and planning by many members of the organization. It often requires a devoted champion willing to undertake this cause.2,15–17 The most important external factors influencing MDI+S implementation in the PED are the safety and feasibility of reusing spacers, cost to the PED, parental perceptions, and perceived increase in nursing workload.

    View all citing articles on Scopus
    View full text