Estrategias para Implementación de las GPC

Andrew D. Oxman

Investigador, Unidad de Salud Global, Norwegian Institute of Public health

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)

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

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

Categories of resources

1. General resources

Selecting healthcare issues to improve2. Stakeholder involvement3. Priority setting4. Clinical practice guidelines5. Measuring performance

Designing interventions6. Identifying determinants of practice 7. Designing the intervention

8. Evaluating interventions

9. Quality improvement programs

1. General resources• Books• Journals• Websites

Contents

1. Implementation of changes in practice2. Theories on implementation of change in healthcare3. Effective implementation: a model4. Characteristics of successful innovations5. Clinical guidelines as a tool for implementing change

in patient care6. Determinants of effective change7. Methods to identify implementation problems8. Selection of strategies9. Dissemination of innovations10.Educational interventions11.Feedback and reminders12.Organisational and financial interventions

1. General resources• Books• Journals• Websites

Contents

1. Introduction2. Practical actions for health care providers3. Identifying a high-quality evidence base4. Key challenges to implementation and effective

interventions5. Using financial systems to support improved care

packages6. Using measurement to support change and

improvement in health care7. Conclusion and reflections

1. General resources• Books• Journals• Websites

1. General resources• Books• Journals• Websites

1. General resources

https://cebgrade.mcmaster.ca/guidelinechecklistonline.html

2. Stakeholder involvement

• Priority setting• Guidelines• Indicator development• Quality improvement• Evaluation

3. Priority setting

Roderik Viergever 2010

4. Guidelines

• Networks• Databases• Methods

4. Guidelines

• Networks• Databases• Methods

5. Measuring performance

• Indicators• Indicator development• Measurement methods

Thomas Kötter 2012

Methods for guideline-based development of quality indicators - a systematic review

6. Identifying determinants

7. Designing interventions

• Evidence• Methods

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.

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

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

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 categoriesIdentify content and implementation options•Step 7: Identify behaviour change techniques (BCTs)•Step 8: Identify mode of delivery

• 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

NorthStar

9. Quality improvement programs

• Guidance & tools• Examples

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.

Questions or comments?