Guidelines do not implement themselves
Guidelines require investment and action to encourage adoption and operationalisation of the recommendations in practice. ‘Implementation’ is the process of putting recommendations into practice (NICE 2014) and requires thoughtful strategising, planning, consultation and partnership early and throughout the guideline development process. It is important to remember that implementation planning is not just filling in a template or completing a checklist. The focus should be more about documenting the structured thinking and interactions between the guideline development group, stakeholder consultations, surveys and public consultation. It is the documentation of these ‘trains of thought’ with consideration of the priorities, structures and policies in multiple settings that are most helpful to guide decisions about effective implementation strategies.
Guideline implementation is highly dependent on the local context, the people involved and available resources. It is likely that different people from those on the guideline development group will need to be involved in implementation planning and execution — which often results in implementation being funded as a separate activity in Australia. For instance, the Australian Dietary Guidelines have a core set of messages about healthy eating; however, the way this would be promoted and to whom this would be targeted will be different for schools and childcare centres — even though the overall goal of children eating healthy food is the same. Many public and environmental health guidelines are funded and implemented by one organisation — for example, the Australian Government Department of Health — but developed by another. This is typically the NHMRC.
There is an extensive body of literature discussing and evaluating different implementation strategies and tools (Grimshaw, Schunemann et al. 2012; Gagliardi, Brouwers et al. 2015; Gagliardi, Marshall et al. 2015). However, the focus of this module is on identifying points during the guideline development process where information can be documented to assist yourself or others to implement the guideline.
What you can do
1. Make your guideline as implementable as possible
One of the key things you can do as a developer to assist implementation of your guideline is to make sure that it is in the best possible shape to be implemented. Key examples include that recommendations are clear and actionable and interventions are described with enough detail to be replicated. This is covered in more detail in the Implementability module.
Ensure that important information about implementation is presented alongside the guideline recommendations. This might include information on how accessible a treatment is, the cost to the patient or the cost to the health system.
Guideline developers should also consider carefully whether to discuss treatments that may fall within the scope of the guideline but which are not available in Australia.
2. Gather information about implementation throughout development
Discussions about guideline implementation may happen in the initial scoping phase of a guideline when evidence-practice or knowledge gaps are being identified. If a guideline already exists in this field, but is presumably out of date, the first question you should ask is whether it was implemented and, if so, whether it was implemented successfully. Evaluation data are rarely available for guidelines in Australia (NHMRC 2014) and so it is likely that you will need to gather this information through stakeholder consultation. In this initial phase of guideline development it is important to document any discussions or feedback, whether formal or informal, regarding implementation ideas to inform future activities.
Opportunities to gather information to inform later implementation of your guideline could occur alongside planned development activities:
- When establishing the guideline development group: consider including someone who currently works in the area of implementing any guideline. For example, in the public or environmental health sectors, someone involved in developing public health policy and/or using the guideline in a regulatory capacity.
- During scoping ask questions from key organisational bodies about what the priorities for implementation might be. For example, distributing a survey to medical colleges to ask ‘What do you perceive are the evidence to practice gaps in managing this condition in your healthcare setting?’
- When updating an existing guideline check any evaluation report of the guideline, and/or ask end users for feedback on what works and doesn’t work in the current version.
- During the evidence review include questions specific to implementation as part of the evidence review process. For example, in an infection control guideline ‘What are the perceived barriers to hand-washing in childcare centres?’
- During recommendation development include and document discussion by the guideline development group of implementation issues that might arise with a specific recommendation.
- During public consultation ask the public questions about implementation. For example, ‘Do you feel able to implement this recommendation in practice? Or what would help you apply these recommendations in practice?’
Or you might also like to organise specific activities such as:
- a workshop once the guideline recommendations have been drafted to discuss implementation priorities with the guideline development group and other relevant stakeholders
- a survey targeting a range of sectors who will be impacted by the recommendations to seek their views on barriers and enablers to implementing the recommendations
- face-to-face meetings with specific groups who are likely to implement the guidelines in their sector
- a session at a relevant conference to talk about or promote the guidelines.
It is important to create a summary report of these consultation activities to feedback to participants and to handover to groups responsible for implementation.
The ‘baton pass’
Successful implementation hinges on the development of strong working relationships and a shared commitment to collaboration. It is likely that many different groups will have an interest in your guideline and the overall goal, but they are likely to have different sets of implementation priorities. While you don’t have to design various implementation strategies you do need to think about which groups will be interested in implementing the recommendations (see the Engaging stakeholders module).
Your role as a developer is to hand the guideline over to these groups in a form that is appropriate for them to implement in their context — hence the term ‘passing the baton’.
For example, if you are developing a guideline on healthy eating for children, your role is to make sure that schools have the key messages for healthy eating (see the Dissemination and communication module); that they have the evidence to back these messages; and that they have access to any contextual information that could help them implement the guidelines, if it is available from consultation activities. The school can then decide how these messages should be delivered and to which people.
If an organisation is responsible for the full cycle of development, implementation, evaluation and updating of a guideline, they are uniquely positioned to be inventive and responsive to user needs. Implementation can then become an ongoing and iterative process throughout the cycle of development. The National Blood Authority and the Stroke Foundation guidelines are good examples of a full cycle of development.
What to include in an implementation strategy or plan
NHMRC's Procedures and requirements for meeting the 2011 NHMRC standard for clinical practice guidelines states that guideline developers should consider including an implementation plan in their guideline.
It may be that you have enough information gathered during the development process to know what strategies to use, but there is a wealth of literature that discusses implementation strategies. A good place to start for general information is the Cochrane Library, the G-I-N website or the journal Implementation Science.
If you are developing an implementation plan it should be based on sound project management principles and:
- include the basic goals and objectives, that is, outcomes you want to achieve
- identify the priority recommendations or key messages
- identify the target audience and context where the recommendations should be applied
- describe the activities suggested to achieve these outcomes
- outline the resources — costs, people, training requirements, facilities — needed to carry out activities
- outline timeframes, including any information that might impact these timelines, such as new evidence published, or new pharmaceuticals or devices that might be released
- outline who is responsible for carrying out the tasks and for signing off on tasks
- outline how outcomes can be measured and what success would look like
- be precise about risks — their source, likelihood of occurrence, consequence and mitigation strategies.
For example, if you wanted to encourage childcare workers to wear gloves while changing nappies as recommended in the Staying Healthy: Preventing infectious diseases in early childhood education and care services guidelines you might plan an implementation activity by breaking it down into the components outlined in Table 1 (immediately below).
Table 1: Implementation activity planning
Examples of guideline implementation plans
Guideline developers who have published implementation plans include:
- National Blood Authority
- Cognitive Decline Partnership Centre
- Centre for Research Excellence in Polycystic Ovary Syndrome.
Guidelines approved by NHMRC must meet the requirements outlined in the Procedures and requirements for meeting the NHMRC standard. The following requirements are not mandatory for NHMRC approval but considered desirable to facilitate the implementation of a guideline:
- G.3 A practical implementation plan is provided as a separate document, based on considerations of the Australian health care context and identification of appropriate organisation/s where the key recommendations may be directed.
- G.4 Resources to support implementation of the guidelines are developed, such as summaries and other tools for different health care professionals, and the guideline indicates where these can be obtained.
- G.5 Accompanying consumer information is provided.
- G.6 Versions of the plain English summary and consumer information are available in different languages, if appropriate.
- G.7 Suggestions for local adaptation and adoption of the guideline are provided.
- G.8 Measures are developed for determining the extent to which key guideline recommendations are implemented.
- G.9 An evaluation strategy is developed and described to assess the extent to which guideline recommendations are adopted into routine practice.
The following Standards apply to the Implementation module:
1. To be relevant and useful for decision making guidelines will:
1.2 Clearly state the purpose of the guidelines and the context in which it will be applied
1.4. Be feasible to implement.
5. To be focused on health and related outcomes guidelines will:
5.2 Address outcomes that are relevant to the guidelines’ expected end users
5.3 Clearly define the outcomes considered to be important to the person/s who will be affected by the decision, and prioritise these outcomes.
9. To be accessible guidelines will:
9.1. Be easy to find
9.2. Ideally be free of charge to the end user
9.3. Be clearly structured, easy to navigate and in plain English
9.4. Be available online.
Queensland Health — Guideline implementation checklist
Registered Nurses Association of Ontario (RNAO) — Toolkit: implementation of best practice guidelines (Second edition)
Gagliardi, A. R., Marshall, C., et al. (2015). "Developing a checklist for guideline implementation planning: review and synthesis of guideline development and implementation advice." Implementation Science 10(1): 1-9.
Grimshaw, J. M., Schunemann, H. J., et al. (2012). "Disseminating and implementing guidelines: article 13 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report." Proceedings of the American Thoracic Society 9(5): 298-303.
NHMRC would like to acknowledge and thank Professor Sally Green from Cochrane Australia for her contribution to the development of this module as editor. We would also like to thank members of the NHMRC Health Translation Advisory Committee (HTAC) for their advice on the scope of this module.
Version 5.0. Last updated 6 September 2019.
Suggested citation: NHMRC. Guidelines for Guidelines: Implementation. https://nhmrc.gov.au/guidelinesforguidelines/implement/implementation. Last updated 6 September 2019.