Getting Guidelines into Practice: Lessons Learned from Research

Jenny Ploeg, RN, PhDEvidence-Informed Decision Making Workshop

McMaster UniversityMay 4, 2011

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Outline

Developing Guidelines Appraising Guidelines Implementing Guidelines Sustaining Guidelines Spreading Guidelines

Question

What guidelines has your organization implemented?

What guidelines have you been involved in implementing?

Practice Guideline Evaluation and Adaptation Cycle (Graham et al, 2005)

Sources of Guidelines

National Guideline Clearinghouse Registered Nurses Association of Ontario And many others

RNAO Guidelines Program

Launched Nursing Best Practice Guidelines Program with funding from MOHLTC in 1999

42 published guidelines: English, French, Chinese, Italian, Japanese, Spanish

Guidelines for Personal Digital Assistants Educator’s Resource Toolkit for Implementation of Clinical Practice

Guidelines

RNAO Guidelines Program

Best Practice Spotlight Organizations Champions Program Advanced Clinical/Practice Fellowships Long-Term Care Best Practices Initiative National Collaborative on Falls in LTC PhD Fellowships

Developing Guidelines

RNAO Development Panel Continence ConstipationProcess of updating now, new evidence being

integrated

Levels of Evidence: RNAO Ia Evidence from meta-analysis or systematic

review of RCTs Ib Evidence from at least 1 RCT IIa Evidence from at least 1 well designed

controlled study without randomization IIb Evidence from at least 1 other type of well-

designed quasi-experimental study III Evidence from well-designed non-

experimental descriptive studies (e.g, correlation studies, case studies)

IV Evidence from expert committee reports or opinions and/or clinical experience of respected authorities

Appraising Guidelines

AGREE II tool (Appraisal of Guidelines for Research and Evaluation)

Assesses methodological rigor and transparency in which a guideline is developed

Appraising Guidelines

23 items in 6 domains Domain 1: Scope and Purpose Domain 2: Stakeholder Involvement Domain 3: Rigour of Development Domain 4: Clarity of Presentation Domain 5: Applicability Domain 6: Editorial Independence7-point scale: 1=strongly disagree, 7=strongly agree

Copyright ©2010 Canadian Medical Association or its licensors

Harrison, M. B. et al. CMAJ 2010;182:E78-E84

Figure 1: The knowledge-to-action cycle

RNAO Toolkit

Toolkit for implementation of clinical practice guidelines

Contents of Toolkit Stakeholder engagement (assessment form) Environmental readiness (assessment form) Evaluation of CPG implementation and impact (indicator

identification worksheet) Human and financial resources (Budget worksheet) Managing and monitoring implementation (action plan

template)

Implementing Guidelines

Edwards, Davies, Ploeg, Dobbins, Skelly, Griffin, Raphs-Thibodeau. (2005). Evaluating best practice guidelines. Canadian Nurse, 101, 19-23.

Facilitators: Questions

From your experience, what are the three most important factors that facilitate guideline implementation?

Study: Facilitators and Barriers

Design: Before-after study with quantitative and qualitative data collection

Setting: 22 agencies in Ontario that implemented 7 RNAO best practice guidelines from 2000-2001 (6-9 month implementation period)

Ploeg, Davies, Edwards, Gifford & Elliott Miller. (2007). Factors influencing best practice guideline implementation: Lessons learned from administrators, nursing staff and project leaders. Worldviews on Evidence Based Nursing, 4, 210-219.

Study: Facilitators and Barriers

Guidelines: Client Centered Care Crisis Intervention Healthy Adolescent Development Pain Assessment Pressure Ulcers Supporting and Strengthening Families Therapeutic Relationships

Study: Facilitators and Barriers

Data Collection: Semi-structured audio-taped telephone interviews

at end of guideline implementationParticipants: 8 Clinical Resource Nurses (Implementation

leaders) 58 Nurses and other care providers 59 Administrators

Facilitators

Individual: Learning about the guideline

through small group interaction

Positive staff attitudesOrganizational: Leadership support Champions Teamwork and collaboration

Environmental: Professional

association support Inter-organizational

collaboration and networks

Lessons Learned Attend to factors at multiple levels:

individual practitioner, social context, organizational and environmental contexts

Leadership support is key Champions Use of toolkits to help plan for

implementation Factors influencing implementation are

interlinked in complex ways not yet fully understood

Sustaining

Knowledge inquiry

Knowledge synthesis

Knowledge tools/

products

Tailo

ring

kno

wle

dge

Knowledge Creation

Identify Problem

Identify, Review Select knowledge

Adapt knowledgeto localcontext

Assess barriers

to knowledge use

Select, tailorimplement

interventions

Monitorknowledge

use

Evaluateoutcomes

Sustainknowledge

use

Knowledge to Action

from: Graham et al: Lost in Knowledge Translation: Time for a Map?

http://www.jcehp.com/vol26/2601graham2006.pdf

Sustainability: Questions

Has your organization been able to sustain the guideline after initial implementation?

What factors are most important for sustainability of guidelines?

Only 2 of 1000 sources screened for a literature review about the diffusion of innovations in health service organisations included the term sustainability (Greenhalgh et al., 2005)

Shorter-term perspectives are the focus of health services research, possibly due to:– Limited availability of long-term funding– Different time perspectives of policy cycles across health care

sectors– Disengagement of project leaders towards the end of projects

Why is sustainability planning rarely addressed in research?

Study: Determinants of the Sustained Use of Research (SURE)

Investigators: Barbara Davies Nancy Edwards Jenny Ploeg Evangeline Danseco Tazim Virani Maureen Dobbins Project Coordinator: Cindy Versteeg Partners: RNAO Canadian Nurses AssociationFunders: CIHR and CHSRF

Sustainability

The degree to which an innovation continues to be used after initial efforts to secure adoption are completed (Rogers, 2003)

When new ways of working become the norm (Maher et al, 2007)

The Issue Up to 70% failure rate for organizational change and 30%

for health care change (Maher, et al. 2010) First 17 RNAO guidelines implemented from 2000-2004 Six-month pilot implementation process, funded by

MOHLTC Once the initial pilot implementation funding is over, do

nurses, managers and senior executives continue to implement guideline recommendations?

The TopicsCycle 1 Falls Continence Constipation Pressure ulcers (Assessment)Cycle 2 Healthy adolescents Client centered care Crisis intervention Pain Therapeutic relationships Pressure ulcers (management) Supporting familiesCycle 3 Adult asthma control Breastfeeding Screening for delirium, dementia and depression Smoking cessation Reducing foot complications for people with diabetes Venous leg ulcers

Results

Participation rate:90% Organizations (37/41) hospital, LTC, community92% Decision-makers (112/122)80% Nurses (77/96)

Sustainability Status at Year 2

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Figure 1. Sustainability Status at Year 2, N=37

Not Sustained

Sustained

Sustained+Expanded

Sustainability Status at Year 2

43% Sustained (16/37);Of the 16 sustained, 11 (30%)

expanded 57% Not sustained (21/37);

Most not sustained in the first and second cohorts (81%)

Sustainability Status at Year 3

59% sustained or sustained and expanded (22/37)

Organizations not sustaining at Year 2, likely not to sustain at Year 3 (9/12 or 75%)

Organizations sustaining and expanding at Year 2, likely to sustain at Year 3 (10/11 or 91%)

Facilitators for Sustained or Expanded Long-Term Use of Guidelines

Leadership by champions Management support at all levels Ongoing staff education Guideline integrated into policies and procedures Staff buy-in and ownership Synergy with partners and external influences Guideline characteristics Multidisciplinary involvement

Implications

To ensure sustainability, we need: Ongoing and supportive leadership Management support Continuing education Organizational culture to support evidence-

informed practice Integration of guideline recommendations into

organizational policies, procedures, documentation

Implications

Administrators and managers need to visibly support the guideline through provision of resources and staff education

Staff education on guidelines needs to be ongoing Managers need to ensure there is funding for staff

education and time for staff to attend education sessions during regular work hours

Guideline recommendations can be integrated into staff orientation and other professional development programs

SURE Study Conclusions

Implementing changes in nursing practice to be more evidence-based takes time, is dynamic, long-term and iterative process

Some organizations may take 2-3 years to show that guideline recommendations are routine part of nursing practice

Full Report: CHSRFhttp://chsrf.ca/final_research/ogc/pdf/davies_final_e.pdf

Spread Kudzu: vine that was introduced to the US from Japan in

1876 One of fastest growing vines Now covers over 7 million acres in Southwestern US Grows as much as a foot per day in summer, climbs trees,

power poles, homes Can grow 60 feet per year

Research, Exchange and Impact for System Support (REISS)

Co-Principal Investigators

Nancy Edwards, RN, PhD, FCAHS.Professor, University of Ottawa

Doris Grinspun, RN, MSN, PhD, O.ONT. Executive Director, Registered Nurses’ Association of Ontario

REISS Research Co-InvestigatorsAngela Downey Associate Professor, University of

VictoriaTazim Virani Principal, Tazim Virani and

Associates

Ali Dastmalchian Professor & Dean, Faculty of Business, University of Victoria

Ian Graham Associate Professor, University of Ottawa

Irmajean Bajnok Director, IABPG Program & CPNE, Registered Nurses Association of Ontario

Ariella Lang Research Scientist, VON Canada

Whitney Berta Associate Professor, University of Toronto

Heather McConnell Associate Director, IABPG Program, Registered Nurses Association of Ontario

Sheila Block Registered Nurses Association of Ontario Ann Lynch Associate Director General of Clinical Operations, MUHC

Barbara Davies Professor, University of Ottawa Patricia Marck Associate Professor, University of Alberta

Kathryn Higuchi Associate Professor, University of Ottawa Cecile Michaud Associate Professor, Université de Sherbrooke, Campus de Longueil

Jenny Ploeg Associate Professor, McMaster University

Suresh Kalagnanam Associate Professor, University of Saskatchewan

Jennifer Skelly Associate Professor, McMaster University

Kim Jarvi Senior Economist, Registered Nurses Association of Ontario

Judith Ritchie Associate Director for Nursing Research, MUHC; Professor, School of Nursing

REISS: 5 Projects

1. Champions Promoting the Use of Best Practice Guidelines 2. Early Steps In Innovation: What Takes a Good Idea Further?

– early postpartum discharge– minimal restraint use– needle-exchange program

3. Spreading Innovation4. Improving Communication to Improve Long Term Care5. What Drives Cost and Enhances BenefitsProject summaries available: Nursing Best Practice Research Unit

Project 1: Best Practice Champions

Ploeg, J., Skelly, J., Rowan, M., Edwards, N., Davies, B., Grinspun, D., Bajnok, I., Downey, A. (2010). The role of nursing best practice champions in diffusing practice guidelines: A mixed methods study. Worldviews on Evidence Based Nursing, 7, 238-251. doi:10.1111/j.1741-6787.2010.00202.x

Background

Definition of Champions: individuals who dedicate themselves to supporting, marketing, and driving through an innovation (Greenhalgh et al., 2005)

Variety of terms used: change agents, opinion leaders, facilitators, linking agents, product champions, best practice champions

Over 3,000 champions trained by RNAO since 1999

Background

“Knowing how champions contribute to projects is critical to understanding, managing, and facilitating innovation and to training others how to champion projects” (Markham, 1998)

Little research on Nursing Best Practice Champions: roles, activities and factors influencing their role

Research evidence of impact is mixed, nature of role remains unclear

Most research conducted in acute care settings

Research Questions

How do Nursing Best Practice Champions influence the diffusion of BPG recommendations?

What factors influence the role of Nursing Best Practice Champions?

Interpretation QUAL + QUAN

QUALQUAN

QUALdata collection

QUALresults

Develop survey instrument

QUAN data collection

QUAN data analysis

QUAN results

Figure 1. Study Design: Mixed Methods Sequential Triangulation Design Phase 1 Phase 2

Note: QUAL: Qualitative; QUAN: Quantitative

Design

Participants

Qualitative Interviews23/26 (88.5%) Champions

Quantitative Survey191/885 (21.6%) Champions 41/110 (37.3%) Administrators

Participants: Healthcare Sector

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Findings

Champions: hold multidimensional roles: educator, facilitator, mentor,

leader, policy developer, evaluator are active knowledge disseminators of clinical information

to nurses work with various disciplines in all types and levels of

positions to explain, convince and help ensure guideline implementation

Findings

Champions: use many strategies at multiple organizational

levels attend to various stakeholder groups tailor diffusion strategies to organizational context

Diffusion Strategies of Champions1. Dissemination of information about clinical practice guidelines

– Education and awareness– Acting as a resource to support and mentor nurses

2. Champions as persuasive practice leaders– Working through committees– Participating in and leading interdisciplinary teams

3. Tailoring the guideline implementation strategies to the organizational context

– Exploring, auditing, monitoring of best practices– Documentation changes to incorporate best practice

recommendations

Spread Within Organization by Setting

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Spread Beyond Organization by Setting

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Y e s N o

Factors Associated with Spread: Logistic Regression Analysis

Spread from a unit/team within an organization was dependent on the success of the implementation strategies

For every 1 unit ↑ in success of implementation you are 2.0 times as likely to have a BPG spread beyond a unit or team

Spread outside the organization was dependent on the extent of change in team unit practices

For every 1 unit ↑ in extent of change you are 6.8 times as likely to have a BPG spread beyond the organization

Discussion Champions hold multiple roles:

facilitator, change agent, knowledge translator Champions are persuasive practice leaders, work with

many disciplines Champions work through complex web of committees and

working groups Champions are adaptors who tailor BPG implementation

strategies to organizational context

Implications Adequate and ongoing training to maximize potential of

champions role and impact Broad range of knowledge and skills: knowledge transfer,

policy development, research and evaluation, leadership, mentorship

Future Research What criteria should be used to select champions? Are characteristics of champions associated with

effectiveness? (e.g., position, credibility, experience) Examine power, span of control, authority of champions What organizational supports are required for success of

champions’ role? What constitutes a ‘critical mass’ of champions? What is the impact of champions?

Study 3: Spreading Innovation – The Best Routes to Best Practices

Barbara Davies, Judith Ritchie and team

What We Studied:

Examined naturally occurring diffusion of guidelines - how practice guidelines spread within and between organizations under normal, everyday conditions.

Phase 1: We created diagrams to map how innovations spread within and outside an organization, two years after implementation of an RNAO BPG. Phase 2: We then visited 2 sites 7-10 years after original introduction.

Results

Phase 1: Spread diagrams revealed the dynamic

and non-linear processes occurring in organizations as they adaptively facilitated the spread of a guideline.

Most sites, except for a community care site, had a higher level of internal organizational) spread than external spread.

Phase 2 Hospital (Acute)

Initially funding was allocated to guideline implementation but currently “in-kind” implementation is ongoing

Guideline implementation of the index topic (supporting families ) continues to be sustained 10 years later

Phase 2 Community Home Visiting

Guideline implementation of the index topic (venous leg ulcers) continues to be sustained 7 years later

Challenges, some of the guideline-based requests to the case managers at the funders (CCACs) are not supported.

The spread diagram was modified to reflect the central and multi-faceted “political funding support/interference process” of the CCACs in a diamond shape box.

Lessons Learned

Takes a combination of strategies: learning opportunities, champions, discussion, communicating goals Frontline workers “deeply involved” to figure out barriers and ways around themStrong leadership at every level to align vision, goals + activitiesRNAO guidelines were sustained 7 to 10 years later“Absolutely better” to be a patient at the hospital now than 10years earlier

ImplicationsSustaining evidence-informed innovations for the long term depends on full engagement of leaders and staff in their implementation. When people feel involved, they will see its value and benefits and stick with it in the long term.

Overall Program of Research: Model

Guideline Implementation for Improved Client/patient Outcomes:

A longitudinal multi-site study

Academic Investigators1.Nursing, uOttawa: Barbara Davies, Kathryn Higuchi, Mary Ann Murray, Jackie Ellis 2.Nursing, McMaster University: Sandra Ireland, Jenny Ploeg3.Clinical Epidemiology Unit, Ottawa Hospital Research Institute: Monica Taljaard

GICOM

Formal three year partnership with RNAO

Focus on enhancing their evidence based nursing practice cultures, and quality outcomes.

RNAO continues to work with the BPSOs to create strategies for sustainability and system-wide spread.

GICOM settings (9)Acute Teaching Hospital: 2Community Hospital: 2Community health centre: 1Home care Nursing: 2Long-term care: 1Rehabilitation care: 1

BPSO Candidates -2009-2012 (16)

NHS sustainability model:A promising developing model

Initiated because sustainability was a problem Aim to identify key factors which support or

hinder sustainability of improvement initiatives Create a model that practitioners could use to

assess the likelihood of sustainability Using a Bayesian approach 250 experts

identified measures, created factors and estimated the diagnostic power of the factor levels

Reported as easy to use Model being used in England, USA, Sweden and

Norway

Sustainability Model(Maher L, Gustafson D, Evans A. NHS Institute for Innovation and Improvement 2010)

Process

Staff

Organization

Senior leaders

Monitoring progress

Adaptability

Credibility of benefits

Benefits beyond helping patients

Infrastructure

Fit with goals and culture

Clinical leaders

Behaviors

Training and involvement

www.institute.nhs.uk/sustainability

Outcomes

Need for more focus on outcomes of implementing and sustaining and spreading guidelines at multiple levels

Implementation of a Falls Prevention Guideline Across the Hamilton Niagara Haldimand Brant Local Health Integration

Network: A Longitudinal Study

Jenny Ploeg, McMaster UniversitySandra Ireland, Hamilton Health SciencesBarbara Davies, University of OttawaKathy Higuchi, University of OttawaMary Ann Murray, University of OttawaKaren Cziraki, Hamilton Niagara Haldimand

Brant Local Health Integration NetworkNancy Fram, Hamilton Health SciencesHelen Kirkpatrick, St. Joseph’s Healthcare

HamiltonAleksandra Zecevic, University of Western

Ontario

Research Questions

1. What are the fall rates and total number of serious falls at three community hospitals providing acute care services within the LHIN before, during and after a mentored implementation of the RNAO Prevention of Falls and Fall Injuries in the Older Adult Best Practice Guideline?

2. What is the projected economic benefit to the LHIN of reducing serious falls (i.e., those resulting in injury) at three community hospitals?

Research Questions

3. What are the experiences of project leaders and decision-makers in community hospitals related to implementing and sustaining a falls prevention guideline? (e.g., strategies used to assist nurses and other health professionals to achieve improvement in fall outcomes; lessons learned in providing feedback related to fall outcomes)

4. What barriers and supports are encountered when implementing and sustaining strategies to improve patient fall-related outcomes over time?

Sustainability Scores for Site 1S u s ta in a b ility S c o re B a r C h a r t

0 2 4 6 8 1 0 1 2 1 4 1 6

B e n e fit s

C re d ib il it y o f th e e vid e n c e

A d a p ta b il it y

M o n ito rin g p ro g re s s

In vo lve m e n t a n d t ra in in g

B e h a vio u rs

S e n io r le a d e rs

C lin ic a l le a d e rs

F it w ith g o a ls a n d c u ltu re

In fra s t ru c tu re

S c o re M a x

Challenges Agreement on common definition of a

serious fall Difficulty experienced by participants in

using the NHS survey Competing pressures and limited

resources within sites Variable stages of implementation of the

Falls BPG at baseline

For details and other publications visit

www.nbpru.ca

www.rnao.org

Thank you: Questions?

Contact: Dr. Jenny PloegEmail: ploegj@mcmaster.caDr. Ploeg is a MOHLTC mid career nursing research

award recipient