"Estrategias para Implementación de las Guías de Práctica Clínica" presentación realizada por Andrew D. Oxman, investigador del Norwegian Institute of Public Health en las Jornadas Científicas de GuíaSalud (Madrid, 4 abril 2016)

1. Estrategias para Implementación de las
GPC
Andrew D. Oxman
Investigador, Unidad de Salud Global,
Norwegian Institute of Public health

2. Jargon
Implementation science
– research relevant to the scientific study of
methods to promote the uptake of research
findings into routine healthcare in clinical,
organisational or policy contexts
Quality improvement
– systematic and continuous actions that lead to measurable
improvement in health care services and the health status of targeted
patient groups
Knowledge translation
– a dynamic and iterative process that includes the synthesis,
dissemination, exchange and ethically sound application of knowledge
to improve health, provide more effective health services and products,
and strengthen the health care system
Ann McKibbon and colleagues have so far identified more than 90
terms for use of research (Sharon Straus 2009)

3. Frameworks, Models and
Theories
Consolidated framework for advancing
implementation Science (Laura Damschroder 2009)
– 5 major domains derived from 14 models: intervention
characteristics, outer setting, inner setting, characteristics of the
individuals involved, and the process of implementation
Thematic analysis of the knowledge translation literature (Vicky
Ward 2009)
– Narrative review of the knowledge transfer literature identified 28
different models which explained all or part of the knowledge
transfer process
TICD checklist for identifying determinants of practice (Signe
Flottorp 2013)
– Systematic review of frameworks and taxonomies resulting in
57 determinants in 7 domains derived from 12 included
checklists

4. Diffusion of innovations in service
organizations (Trisha Greenhalgh 2004)
– Model for considering diffusion of innovations in
health service organizations based on a “meta-
narrative” review of a vast and complex
literature from 13 research areas
Theories on behaviour change to guide
implementation and quality improvement
(Michel Wensing 2005)
– 30 factors derived from 29 theories from
psychology, sociology, economics, education
and management
Frameworks, Models and
Theories

5. Categories of resources
1. General resources
Selecting healthcare issues to improve
2. Stakeholder involvement
3. Priority setting
4. Clinical practice guidelines
5. Measuring performance
Designing interventions
6. Identifying determinants of practice
7. Designing the intervention
8. Evaluating interventions
9. Quality improvement programs

6. 1. General resources
• Books
• Journals
• Websites
Contents
1. Implementation of changes in practice
2. Theories on implementation of change in healthcare
3. Effective implementation: a model
4. Characteristics of successful innovations
5. Clinical guidelines as a tool for implementing change
in patient care
6. Determinants of effective change
7. Methods to identify implementation problems
8. Selection of strategies
9. Dissemination of innovations
10.Educational interventions
11.Feedback and reminders
12.Organisational and financial interventions

7. 1. General resources
• Books
• Journals
• Websites
Contents
1. Introduction
2. Practical actions for health care providers
3. Identifying a high-quality evidence base
4. Key challenges to implementation and effective
interventions
5. Using financial systems to support improved care
packages
6. Using measurement to support change and
improvement in health care
7. Conclusion and reflections

8. 1. General resources
• Books
• Journals
• Websites

9. 1. General resources
• Books
• Journals
• Websites

10. 1. General resources
https://cebgrade.mcmaster.ca/guidelinechecklistonline.html

11. 2. Stakeholder involvement
• Priority setting
• Guidelines
• Indicator development
• Quality improvement
• Evaluation

12. 3. Priority setting
Roderik Viergever 2010

13. 4. Guidelines
• Networks
• Databases
• Methods

14. 4. Guidelines
• Networks
• Databases
• Methods

15. 5. Measuring performance
• Indicators
• Indicator development
• Measurement methods
Thomas Kötter 2012
Methods for guideline-based development of quality indicators - a systematic
review

16. 6. Identifying determinants

17. 7. Designing interventions
• Evidence
• Methods

18. Effect of interventions for implementing
clinical practice guidelines: an overview
of systematic reviews
• Implementation interventions such as electronic decision-support,
educational meetings, outreach visits, audit and feedback, and
tailored interventions are probably effective, but:
- The size of the effect varies
- The effect on clinical practice is most often moderate
- The expected effect on health outcomes is modest
• For other of the interventions, the size of the effect varied
considerably across studies. It is difficult to explain this variation.
Consequently, it is uncertain how much these interventions will
improve adherence to clinical guidelines
• For some measures, such as financial incentives and public release
of performance data, evidence is lacking or scarce. We therefore
cannot say how effective these types of interventions are
Fretheim A, Flottorp S, Oxman AD. Rapport fra Kunnskapssenteret nr. 10−2015.
Oslo: Nasjonalt kunnskapssenter for helsetjenesten, 2015.

19. There is moderate certainty evidence
that the following interventions probably
increase adherence to clinical practice
guidelines
• Clinical decision-support systems
(including reminders)
• Educational outreach visits (including
«practice facilitation»)
• Audit and feedback
• Local opinion leaders
• Tailored interventions
• Educational meetings

20. It is uncertain whether the following
strategies improve adherence to clinical
practice guidelines because the
certainty of the evidence is very low:
• Internet-based learning
• Interprofessional education
• Printed educational materials
• Economic incentives
• Interprofessional collaboration
• Checklists
• Strategies to change organisational culture
• Public release of performance data

21. 7. Designing interventions
• Evidence
• Methods Understand the behaviour
•Step 1. Define the problem in behavioural terms
•Step 2. Select the target behaviour
•Step 3. Specify the target behaviour
•Step 4: Identify what needs to change
•Optional Step 4a: Identify what needs to change using
the Theoretical Domains Framework (TDF)
Identify intervention options
•Step 5: Identify intervention functions
•Step 6: Identify policy categories
Identify content and implementation options
•Step 7: Identify behaviour change techniques (BCTs)
•Step 8: Identify mode of delivery

22. • A tool to help evaluators of interventions to
improve the quality of healthcare
– For quality improvement researchers and
healthcare professionals and managers
responsible for developing, delivering and
evaluating quality improvement programmes
8. Evaluating interventions

23. NorthStar

24. 9. Quality improvement programs
• Guidance & tools
• Examples

25. 9. Quality improvement programs
• Guidance & tools
• Examples
Academic Health
Science Networks’
goal is to improve
patient and population
health outcomes by
translating research
into practice, and
developing and
implementing
integrated health care
services.

26. Questions or comments?