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Implementation Guide February 2016

for evidence-based clinical practice guidelines in health institutions in colombia

Implementation manual

copy Ministerio de Salud y Proteccioacuten Social

Departamento Administrativo de Ciencia Tecnologiacutea e Innovacioacuten ndash Colciencias

Implementation manual for evidence-based clinical practice guidelines in health services provider institutions in Colombia

ISBN 978-958-8903-08-8Bogotaacute Colombia2014

This document has been prepared under contract 478 2013 of Ministerio de Salud y Proteccioacuten Social and the Universidad de Antioquia

ALEJANDRO GAVIRIA URIBEMinister Of Heath And Social Protection

FERNANDO RUIZ GOacuteMEZDeputy Minister of Heath and Service Provision

NORMAN JULIO MUNtildeOZ MUNtildeOZDeputy Minister of Social Protection GERARDO BURGOS BERNALGeneral Secretary

JOSEacute LUIS ORTIZ HOYOSHead Quality Office

HEacuteCTOR EDUARDO CASTRO JARAMILLO Executive Director

AURELIO MEJIacuteA MEJIacuteA Deputy Director Health Technology Assessment

IVAacuteN DARIacuteO FLOacuteREZ GOacuteMEZDeputy Director Clinical Practice Guidelines JAVIER HUMBERTO GUZMANDeputy Director Implementation and knowledge transfer DIANA ESPERANZA RIVERA RODRIacuteGUEZ Deputy Director Participation and Deliberation

SANDRA LUCIacuteA BERNALDeputy Director Communications

Manual Developer Group

AuthorsAndreacutes Duarte OsorioThematic ExpertPontificia Universidad JaverianaPhysician and Surgeon Specialist in Family Medicine MSc in Clinical Epidemiology

Ana Marcela Torres AmayaThematic ExpertUniversidad Nacional de ColombiaPharmaceutical Chemist MSc in Clinical Epidemiology

Claudia Marcela VeacutelezThematic ExpertUniversidad de AntioquiaPhysician and surgeon Specialist in public health management and social security MSc in Clinical Science

Academic Director Rodrigo Pardo TurriagoUniversidad Nacional de ColombiaSurgeon Specialist in Clinical Neurology MSc in Clinical Epidemiology

Education TeamMichelle Corteacutes BarreacuteExpert in EducationPontificia Universidad JaverianaPhysician Masterrsquos in Education MSc in Clinical Epidemiology

Carlos Goacutemez RestrepoThematic ExpertPontificia Universidad JaverianaHospital Universitario San Ignacio Psychiatrist psychoanalyst psychiatrist liaison MSc in Clinical Epidemiology

Socialization TeamMariacutea del Pilar PastorExpert in Qualitative ResearchUniversidad de AntioquiaNurse MSc in Public Health PhD in Public Health Sciences

Vivian Marcela Molano SotoExpert in communicationUniversidad Nacional de Colombia Social communicator-Reporter MSc in Political Studies

Luz Helena Lugo AgudeloRepresentative CPG Developer GroupsUniversidad de AntioquiaMedical physiatrist MSc in Clinical Epidemiology

Vanesa Andreiacutena SeijasPilot Study SupportUniversidad de AntioquiaPhysician and surgeon

Leonardo Andreacutes Anchique Leal Systems EngineerAlianza Cinets website administrator

Fernando SuaacuterezExpert in Medical InformaticsUniversidad JaverianaGeneticist doctor MSc in Clinical Epidemiology and MSc in Bioinformatics and Medical Informatics

Administrative Support TeamClaudia Marcela VeacutelezManaging DirectorUniversidad de Antioquia

Paula Andrea Castro Garciacutea EconomistUniversidad de Antioquia

Claudia Espinosa Johnson Interpreter and Official Translator Member Colegio Colombiano de Traductores ndash CCTMinistry of Health and Social Protection

Participants in Manual Validation

Validation of Implementation Model

CPG Acute Coronary Syndrome

Juan Manuel SeniorInternist Hemodynamist CardiologistHospital San Vicente Fundacioacuten

Efraiacuten GoacutemezInternist CardiologistCliacutenica Shaio Sociedad Colombiana de Cardiologiacutea

Natalia Tamayo Internist CardiologistHospital San Vicente Fundacioacuten

Aacutengela DiacuteazAdministratorCliacutenica las Ameacutericas

Clara Ineacutes MejiacuteaPhysician auditCAPRECOM

Sebastiaacuten RuizRural doctorESE Copacabana

CPG Pregnancy

Joaquiacuten GoacutemezOB-GYN doctorUniversidad de Antioquia Director of Centro Nacer

Juan Guillermo LondontildeoOB-GYN doctorUniversidad de Antioquia NACER Group

Wilson MartiacutenezPhysicianMetrosalud

Luis Abel AldanaOB-GYN doctorHospital Marco Fidel Suaacuterez Bello and Cliacutenica Saludcoop Villa Nueva branch

Zaira RamiacuterezNurse Hospital Marco Fidel Suarez

Lina Mariacutea AriasPhysician Hospital Marco Fidel Suaacuterez de Bello

Moacutenica PatintildeoPhysician Metrosalud Unidad Hospitalaria de Manrique

Patricia ArbelaacuteezNurseMetrosalud Unidad Hospitalaria de Manrique

Arturo Cardona OspinaOB-GYN doctor Fetal Medicine SpecialistCliacutenica del Prado

Gloria CastantildeoNurse Cliacutenica del Prado

Johana ArangoNurse Cliacutenica del Prado

Manual Validation by Experts and System stakeholders

Ivaacuten Dariacuteo FloacuterezInstitute of Health Technology Assessment

Javier GuzmaacutenInstitute of Health Technology Assessment

Oscar Ariel Barragaacuten RiosQuality Office Ministry of Health and Social Protection

Indira Tatiana Caicedo ReveloQuality Office Ministry of Health and Social Protection

Hernando GaitaacutenHospital Universitario Universidad Nacional de Colombia

Jesuacutes EchavarriacuteaBogotaacute Health Office

Abel Ernesto Gonzaacutelez VeacutelezQuality Office Ministry of Health and Social Protection

Juan AlbornozCliacutenica de los Nogales

Lina Paola BonillaUniversidad Nacional de Colombia

Ana C FernaacutendezInstitute of Health Technology Assessment

Juan Manuel CorreaEPS Compensar

Jorge OrjuelaFundacioacuten Universidad Saacutenitas

Juan Pablo AlzateUniversidad Nacional de Colombia

Daniel Gonzalo EslavaUniversidad Javeriana

Pilot study ndash IPS SURA Medelliacuten

Clara Ximena SuaacuterezNational Audit Director of IPS Sura

Ana Catalina OchoaTechnical management analyst

Juan Carlos SuescuacutenEmergency Coordinator

Isabel Cristina FonnegraAuditor Basic IPS

Cesar Augusto CardonaInformation Analyst

Juan Esteban Holguiacuten Knowledge Management Analyst

Pilot study ndash Hospital de Fontiboacuten

Yidney Garciacutea RodriacuteguezManager

Nancy S Tabares RamiacuterezAssistant manager health services

Claudia P RoseroQuality leader

Liliana Castiblanco MososIntramural outpatient process leader

Marcela Saacutenchez CP and D Programs referent

Edgar FloacuterezAuditor

Diana NaranjoAuditor

Nancy ChacoacutenEpidemiologist

Clara Y PradaHospital Process Leader

Paola C GiraldoEmergency Process Leader

Pilot study ndash Hospital Universitario San Vicente Fundacioacuten

Fernando FortichInternist cardiologist

Yessica GiraldoGuideline group

Luz Marina QuicenoHead of Quality Assurance Office

Juan Fernando LondontildeoHead of Statistics Department

Yuli AgudeloResearch Unit Coordinator

Ministerio de Salud y Proteccioacuten Social - Colciencias 9

Content

1 INTRODUCTION 11

2 GLOSSARY 15

3 THE IMPLEMENTATION PROCESS IN THE COLOMBIAN SOCIAL SECURITY

SYSTEM IN HEALTH 19

31 National CPG Implementation Process 20

32 Scope and population under the CPG national implementation process 20

33 Roles for actors in the system 21

331 Ministry of Health and Social Protection (MSPS) 21

332 Institute for Health Technology Assessment (IETS) 21

333 Guideline Developer Groups (GDG) 22

334 Health Insurers (EPS or APB) 22

335 Health Service Provider Institutions 22

336 Higher Education Institutions 22

337ScientificSocieties 23

338 Associations of users and patients 23

339 Patients 23

4 PHASE 1 PLANNING AND CONSTRUCTION OF THE IMPLEMENTATION PLAN 25

41 CPG Adoption Policy 26

411 Steps for the adoption of CPG 26

42Establishmentoftheinstitutionalimplementationteamanddefinitionofroles 27

43 Creation of institutional implementation plan 27

431 Selection of the Guideline to implement 28

432Identificationofbarriersandfacilitators 28

433Definitionofstrategiesanddisseminationactivities 30

434 Selection of implementation tools 31

435Definitionoftheincentiveplan 31

436Identificationofresourcesneededforimplementation 32

Centro Nacional de Investigacioacuten en Evidencia y Tecnologiacuteas en Salud - CINETS10

437 Preparation of the schedule of activities 32

438 Selection of evaluation and control mechanisms 32

44 Preparation of Baseline 33

45Practicalstepsindefiningtheinstitutionalimplementationplan 33

46 Tips for creating the implementation plan 36

5 PHASE 2 REALIZATION OF IMPLEMENTATION ACTIVITIES 37

6 PHASE 3 IMPLEMENTATION MONITORING AND FOLLOW-UP 41

61 Monitoring 42

62 Evaluation plan for implementing CPG 42

621 Components of the evaluation 43

63 Feedback and adjustments to the implementation plan 43

7 IMPLEMENTATION OF PATIENT GUIDELINES 45

ANNEXES 47

BIBLIOGRAPHY 67

1 Introduction


Introduction

The Institute of Medicine defined the Clinical Practice Guideline as ldquostatements that includerecommendations intended to optimize patient care that are informed by a systematic review of evidence andanassessmentofthebenefitsandharmsofalternativecareoptionsrdquo(1)FromthisperspectiveCPGrecommendationsprovidethebestcareavailablewhileavoidingunjustifiedvariabilityinpracticeusingcontext-sensitiverecommendationsandsometimeswithcosteffectivenessandequityanalysisin order to improve patient health standards

TheformulationofspecificrecommendationsinCPGistheresultofademandingcomplexandrigorousmethodologicalprocessHowever tohaveCPGseven if theyhavebeendevelopedwith themostrefinedmethodologyandappropriate teamsdoesnotguarantee theiruse inclinicalpractice theirfavorableimpactonqualityofhealthcaredecreasednegativeoutcomesordecreasedcostsinserviceprovision

ThustheinvestedeffortandresourcesoftheCPGdevelopmentdonotnecessarilytranslateintoGPGadoptionandusebypotentialusersorinexpectedchangesinthequalityofcareandthehealthofthepopulation Numerous population-based studies show poor compliance with the CPG recommendations byprominentprofessionalorgovernmentagenciesforbothacuteandchronicconditions(2-5)

TheprocessesrequiredimplementingtheCPGrecommendationsinclinicalpracticeandCPGusebythehealthcareprovidersandpatientsinordertomakethebestdecisionsinspecificclinicalconditionsinvolve individual institutional and social changes (6)The implementation of aCPG is a complexprocess It is an active process that must be planned and systematically developed and it depends on multiple factors such as the characteristics of the context barriers and facilitators of changeteaching and intervention strategies and competencies of health system actors These considerations seek to successfully incorporate the recommendations into clinical practice A previous diagnosis of thebasalconditionsofpracticeisrequiredtogetherwithknowledgeofregulatoryadministrativeandlegalaspectsAlsothefollowingmustbetakenintoaccounttheprofessionaltechnicalandsupportresourcesorganizationalstructuresandtheircultureprocessauditactivitiescontrolandmonitoringandmanagementassessmentThefactthatcontextsarevariablebothintimeandinspaceimpliesthat there are no magical formulas or universal precautions to implement the CPG

The implementation of recommendations involves challenges for individuals and institutions when changes inclinicalpracticearerequestedand itconnects the jointknowledgeof theadministrationmanagement the dynamic behavior of groups and societies the exercise of rights andduties thecreationofnewopportunitiesformulti-levelworkmanagementandevaluationImplementationshouldbe an exercise of political and social consensus with clear and transparent rules it is also a process that issocialdynamicflexibleandadaptabletochangebutrigoroussequentialandwithabilitytogeneratemeasurableresultsThistopicraisesenormousinterestandcontroversyanditispartofthequalityandequityagendasofplannersdecisionmakersandmanagers

ForseveralyearstheMinistryofHealthandSocialProtection(MSPS)oftheRepublicofColombiahas fostered thedevelopmentofevidence-basedCPGsTo thatend theldquoMethodologicalGuide forthe Development of Guidelines for Comprehensive Care in the General System of Social Security


Implementation manual for evidence-based clinical practice guidelinesin health services provider institutions in Colombia

in ColombianHealthrdquo was developed (7) andwas used for the elaboration of the first twenty fiveColombian CPGs The challenge today is to ensure that the recommendations in the CPGs are put into practicefulfillingthepurposeforwhichtheyweregeneratedandstrengtheningthepoliticaldecisionofworking towardshigh-qualityhealthcareThiswas thereasontodevelopaCPGimplementationmanualasausefultoolflexibleadaptableforthehealthsystemactorsinthedifferentlevelsofcarein Colombia This manual seeks to guide health care providers and patients in the follow-up of CPG recommendationsinordertoprovidequalityandequitycare

Thismanualisbasedontheresultsoftwosystematicreviewsmodelsandimplementationstrategiesdevelopedspecificallyforthisproject(58)anditincludesimplementationrecommendationsraisedinthedifferentCPGsdevelopedfortheGeneralSystemofSocialSecurityinHealth(SGSSS)observationscollectedinfocusgroupswithhealthprofessionals(clinicalandqualitymanagement)andtheresultsof pilot studies at the Hospital de Fontiboacuten at the IPS SURA in the city of Bogotaacute and the Hospital San Vicente Fundacioacuten in the city of Medelliacuten

The systematic review of CPG implementation models (5) included nineteen studies evaluating differentapproachestotheimplementationprocessesandtheyestablishedthattheapproachtoCPGimplementationmustincludeadiagnosisofclinicalpracticeineachcontextonwhichtheimplementationstrategies ought to be designed using educational considerations specialized tools and strategiesfor identifyingbarriersand facilitators in implementingkey recommendations toshapeassessmentprocesses with process and outcome indicators

From a conceptual point of view the systematic review appreciated the flexibility of the PARIHS(PromotingActiononResearch Implementation inHealthServices)model (9)whichpostulates theeffectivenessofimplementationintermsofthreedimensionsthenatureandtypeoftheevidencethequalitiesofthecontextwheretheevidenceisintroducedandthewaytheprocessisfacilitatedThereview also allowed to build a conceptual model (see Annex 1) and identify three major phases in the implementationprocessplanningandconstructionoftheimplementationplan(phase1)executionoftheimplementationactivities(phase2)andmonitoringandtracking(phase3)Thisstructurebecauseofitsrelevancewasusedtostructurethismanual

This manual includes an introduction section a glossary of the most frequently used terms inimplementationadescriptionoftheimplementationprocessintheSGSSSadescriptionofthephasesoftheimplementationprocessacompilationofeducationaltoolsforimplementationdisseminationandmonitoringand thebibliography referencedThephasesof the implementationprocesshavebeensequencedordinallyconsistentwiththeprocessitselfThereforewhattheliteraturereferstoaspre-implementationwillbecalledherephase1theimplementationproperwillbecalledphase2andphase3 will be referred to as post-implementation

Our expectation is that the implementation model developed and the contents of this manual will guide an effective implementation of CPG in health care providers all the while contributing to build anefficientinformationsystem(10)toprovidesupportforupdatingtheimplementedCPGsandfacilitatetheidentificationofsensitiveareasforfutureguidelinedevelopmentprocesses(11)

2 Glossary


Glossary

AdaptationExtenttowhichanevidence-basedinterventionischangedormodifiedbyauserduringthe adoption and implementation to adjust it to the needs of the userrsquos practice or to enhance the performance of local conditions (12)

AdoptionThisreferstothedecisionoftheinstitutionalneedorobligationtochangeclinicalpracticeadjusting it to the recommendations contained in the CPGs (13)

AssessmentValuationoftheefficacyeffectivenessdisseminationorimplementationofanintervention(14)

Assessment of implementation Valuation of how and at what level a program is implemented and what and how much was received by the target population (14)

Barriers Factors hindering dissemination and implementation (14)

CPG Clinical Practice Guideline

DiffusionThisreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersandpotentialusers(13)It isapassiveprocessnotdirectedrelativelyunplannedanduncontrolled to circulate new interventions (18)

Dissemination This refers to processes or activities of effective communication and education that aim to improveormodify theknowledgeandskillsof theendusersof theguidewhether theyareservice providers or patients (13)

EAPBBenefitPlanAdministrators(acronyminSpanish)

EBM Evidence-Based Medicine

EPS Health Promoting Entities (acronym in Spanish)

Facilitators Factors promoting dissemination and implementation (14)

GDG Guideline Development Groups

IETS Institute for Health Technology Assessment (acronym in Spanish)

ImplementabilityFeaturesof theguidelinewhichcan increase thechancesof implementationbyusers (20)

Implementation Process which aims to transfer the recommendations in the CPG to the everyday clinical practice (13)

Implementation Outcomes These are different from the system outcomes They are implementation successmeasuresproximalindicatorsoftheimplementationprocessandintermediateoutcomesthatare key to effectivenessandquality of careThemain valueof the implementationoutcomes is todistinguish intervention failures from implementation failures (17)

Implementation Plan This is the set of guidelines that must be followed to realize and properly disseminate the CPG within each institution



Implementation Strategies Systematicprocessesactivitiesandresourcesthatareusedtointegrateinterventions into usual practice scenarios (19)

MSPS Ministry of Health and Social Protection (acronym in Spanish)

NICE National Institute for Health and Care Excellence

Opinion LeaderMembersofacommunityororganizationwhohavetheabilitytoinfluenceattitudesand behaviors of other members of the organization or community (12)

Organizational Change This occurs when a company makes a transition from its current state to a desired future state (14)

Organizational CultureThis isdefinedas the regulationsandexpectationsabout thebehaviorofpeoplehowtheythinkandwhattheydoasanorganization(16)

Organizational Environment This refers to employee perception and the reaction to the characteristics of the work environment (15)

SGSSS General System of Social Security in Health (acronym in Spanish)

SIGN Scottish Intercollegiate Guidelines Network

SOGC Mandatory System for Quality Assurance in Health (acronym in Spanish)

3 The implementation process in the Colombian Social Security

System in Health


The implementation process in the Colombian Social Security System in Health

The implementation of CPG for the country is a new experience posing new challenges for the SGSSS and the various stakeholders To implement the CPG recommendations in the institutions providing healthservicesinvolvesdesigningplanningandimplementingdiffusionadoptiondisseminationandmonitoringstrategiesinorganizationswithvaryingdegreesofcomplexitywhichinturnprovideservicesindifferentculturalandsocialcontextsofthecountryThiscomplexscenariorequirescomprehensiveandharmoniousworkthatinvolvescommitmentactiveparticipationandresourceallocationfromcentralagencies and governmental institutions (MSPS Institute of Health Technology Assessment IETSHealthSuperintendency)decentralizedinstitutions(HealthPromotingEntities-EPSandHealthCareProviders-IPS)CPGdevelopergroupshealthserviceprovidersusers(userorpatientsassociations)and the general public

The adoption and adaptation of guidelines in a country must obey planned implementation processes with government support and incentives (21) Governments should encourage health institutions to adopttheCPGswhichdoesnotmeanthattheprofessionalandthepatientcannotoptforanalternativediagnostic or therapy different from that recommended in the guide These considerations must aid the understandingofhowthenationalimplementationprocessiswhatisitspurposeandscopeandwhatthe roles of the actors of the system are These aspects should foster the organization given by SGSSS to the new challenge of CPG implementation

31 National CPG Implementation Process

Toensure that theCPGsmeet thepurposes forwhich theyweremade it isnecessary todevelopprocessesthatincludebull RecommendedstrategiesfordiffusionadoptiondisseminationandmonitoringofCPGsbasedon

theevidenceontheireffectivenessindifferentfieldsofapplicationandusebull Creatingscenariosandpermanenteducationconsultationand learningstrategiesaboutCPGto

ensure their proper use and implementation bull Encouragingtheuseofamonitoringevaluation(clinicalandmanagement)andcontrolsystemof

theCPGimplementationtheoperationofwhichensurestoidentifytrendseffectslevelofefficiencyand consistency with corporate policies and the Mandatory System of Quality Assurance in Health (SOGC)

bull Recommendations to the Ministry of Health and Social Protection and the Institute for Health Technology Assessment (IETS) for the incorporation of new technologies (care processes and proceduresdrugsdevicesandequipment) in thebenefitplans inaccordancewith theparticulardevelopment of each CPG

32 Scope and population under the CPG national implementation process TheprimarypurposeoftheimplementationprocessistoensurethatendusersprovidersandpatientsusetheCPGrecommendationsmadeindailyclinicalpracticeHoweverfromabroaderpointofviewitmustmeetthegoalsthatpromoteditsdevelopmentThustheCPGaredesignedsotheycanbeusedby the different SGSSS actors and those of the National System of Science and Technology in Health FirsttheCPGsaredirectedtothoseactorswhorecognizethemastheguidingtechnicalsupportof



careHealthauthoritiesofthenationalandlocallevel(localhealthofficesordivisionsinmunicipalitiesprovinces and districts) public and private health care providers (IPS)BenefitPlanAdministrators(EAPB)orinsurersprofessionalsscientificassociationssurveillanceandcontrolentitiesentitiesinchargeofaccreditationInstituteforHealthTechnologyAssessment(IETS)patientscaregiversandthegeneralpublicSecondlytheyareintendedforthosewhorecognizethemasasourceforgenerationofknowledgeandinnovationandwhoarerelatedtotheparticularCPGobjectiveColcienciashighereducationinstitutionstechnologydevelopmentcentersandresearchgroups

33 Roles for actors in the system

The implementation of CPGs at a national level offers challenges to the entire structure and organization of the SGSSS The following section is a description of the main functions that the various actors in the systemmayhaveintheimplementationprocesswithoutclaimingtobeexhaustiveandassumingthattheycanbemodifiedduetopolicyandregulatoryconsiderations

331 Ministry of Health and Social Protection (MSPS)bull To adopt the CPGs as part of the legitimation process within the SGSSSbull To further the studies to decide whether the CPG recommended technologies are incorporated

intobenefitplansbull TotakethenecessarystepsinINVIMAtoupdateinotherusestheapprovedtechnologiesin

thecountrytakingintoaccounttheCPGrecommendationsbull To process the entry into Colombia of new technologies recommended in the CPGsbull To incorporate compliance with and monitoring of the CPGs developed in the country into the

processesoflicensingandaccreditationofhealthinstitutionsunderhighqualitystandardsbull To develop and maintain a web portal where all the target population can easily and permanently

findallmaterialproducedbyevidence-basedclinicalpracticeguidelinesbull TodefinetogetherwiththeIETSanddevelopergroupsindicatorstomonitortheimplementation

of each CPGbull To establish mechanisms for collecting and processing data for calculating the indicators for

monitoring implementationbull ToincludeinformationofCPGindicatorsintheitemldquoeffectivecarewithCPGrdquointheHealth

Care Quality Observatory and in the Library of National Quality Indicators bull To incorporate the data necessary for the construction of indicators of CPGs in the health

informationsystemSISPROdefiningtheresponsibilitiesofeachoftheactorsinthesystemfor obtaining them

bull To develop incentive plans for institutions and professionals that contribute to the effective adoption of the CPGs These plans must adjust to the framework of Law 100 of 1993 and other institutional incentive and motivation systems available

332 Institute for Health Technology Assessment (IETS)bull To participate in the socialization process of the CPGs and make observations to developer

groups to facilitate their implementability and development of the implementation plans


bull To form regional nodes to facilitate the adoption and implementation process at different levels of care

bull To develop strategies and tools to disseminate and monitor the CPG implementationsbull Toprovide technicalassistance todifferentSGSSSactors topromote thesuccessfulCPG

implementationsbull To participate in institutional adjustment processes directed toward successful CPG

implementationsbull To design or accompany the design and conduct of studies to generate evidence about best

practices in CPG implementation in the countrybull To record the progress and current status ofCPG implementation in partnershipwith the

Ministry of Health and Social Protection

333 Guideline Developer Groups (GDG)bull To convene and facilitate the participation of different SGSSS actors in the socialization and

finaladjustmentoftherecommendationsintheCPGsbull To develop and propose recommendations considering the implementability frameworkbull Tospecifyrecommendationsthatrequirepolicyadjustmentforimplementationandtechnologies

thatarenotinthecountrynotapprovedbytheINVIMAornotincludedinbenefitplansbull To prioritize recommendations for implementation and identify barriers facilitators and

strategies for changebull To propose indicators for monitoring and evaluating the CPG implementation developedbull TosuggestspecificstrategiesforimplementingtherecommendationsintheCPG

334 Health Insurers (EPS or APB)bull To provide information systems that allow collecting data to calculate indicators of CPG

implementationbull To design and implement incentive schemes for institutions and staff contributing to the effective

CPG implementations

335 Health Care Providersbull To design and implement the plan of local CPG implementationsbull To implement the CPGs according to planbull To coordinate the CPG implementations to the institutional enabling and accreditation

processesbull To check and adjust the IPS information systems according to the implementation standards

and indicators proposed in the CPGs

336 Higher Education Institutionsbull To include courses in Evidence-Based Medicine (EBM) in the training programs for human

resources in health and in the relevant subject areas discuss the contents and CPGrecommendations

bull To design and implement continuing education programs in CPG for graduates and health institutions




bull According to the experience and knowledge to accompany the health care providers theMinistry of Health and Social Protection and the IETS in the CPG implementation processes

bull To promote academic discussions and conduct research that will identify and document the effectivenessofimplementationstrategiesandtoolsandidentifytopicstoupdatetheCPGs

337 ScientificSocietiesbull To participate in the socialization process of the CPGs and make observations to developer

groups so as to facilitate the implementation aspects and the development of implementation plans of the CPGs

bull To develop CPG training programs for members and health institutionsbull AccordingtotheexperienceandknowledgetoaccompanythehealthinstitutionstheMinistry

of Health and Social Protection and the IETS in the CPG implementation processesbull Toparticipateintheprocessesofdiffusiondisseminationmonitoringevaluationandupdating

of the CPGsbull To contribute to the creation of a culture of service where the use of CPG becomes a mechanism

ofself-regulationandqualityassurance

338 Associations of users and patientsbull To promote and participate in the processes of diffusion and dissemination of CPGbull To support the CPG implementation

339 Patientsbull To know the CPGs that relate to your health problemsbull To participate in processes of diffusion and dissemination of CPGbull To propose amendments to the CPGs according to their own experiences of care

4 Phase 1 planningand construction of the

implementation plan


Phase1planningandconstructionoftheimplementationplan

TheimplementationprocessofaCPGinahealthserviceprovisioninstitutionincludesdefiningadoptionof institutional policy shaping the institutional team the creation of the institutional plan and thedevelopment of the baseline

41 CPG Adoption Policy

The institutional decision to change clinical practice adjusting it to the recommendations in the CPGs generally belongs at the management level of institutions From the perspective of providers of health services adoption should be understood as a process that involves commitment and institutionaldecision to change the practice and consider the different actors and resources of the health system It isthefirstinstitutionalstepintheimplementationprocess

When the institutions providing health services have completed the process of assessing health problemsandtheneedsoftheiruserstheyshouldcontinueitwiththeprioritizationoftheconditionsto intervene and review the existing CPGs These processes are beyond the scope of this manual and should be reviewed in other reviews and manuals

InColombia theMinistryofHealthandSocialProtectionadoptedbyResolution1442of2013 theCPGsrelatedtocancercareandsubmitsthemasldquonecessaryreferenceforthecareofpersonsbutthe health personnel have the power to accept or not the recommendations when considering that the clinicalcontextinwhichcareisprovidedsowarrantsleavingrecordoftheiropinionanddecisionintheclinicalhistoryrdquo(22)ItalsonotesthattheCPGsadoptedshouldbeldquonecessaryreferenceforBenefitPlansAdministratorsHealthCareProvidersAdaptedEntitiesandSpecialRegimesrdquo(22)

Each Health Care Provider must conduct an adoption process of the CPGs arranged by the Ministry of HealthandSocialProtectionincludingthemasareferenceforthecareoftheirusersandassigningthe necessary resources for institutional dissemination implementation evaluation and controlincorporating them into the framework of the procedures and conditions that the service providers must satisfy to enable health services (23)

The successful implementation at the institutional level requires the genuine commitment of theentire team Management should assume the initial leadership and as the process continues and theimplementationteamisformedsuchleadershipcanbetransferredtotheofficials involvedThemanagement of the institution should develop and disseminate a document where it undertakes to implement the CPG and emphasizes this work as an organizational priority (Implementation Plan) Additionally it must have all the necessary resources to facilitate the process of disseminationimplementationevaluationandcontrol

411 Steps for the adoption of CPGTheleadershipoftheHealthCareProvidershoulda) Ensure that CPG implementation is by a priority administrative orderb) IdentifytheagencyunitordivisionoftheIPSandtheofficialdirectlyresponsibleoftheimplementation

processInmostcasesthisworkwillbeassignedtotheinstitutionrsquosauditorqualityoffices



c) Appoint a representative to accompany the Implementation Teamd) Create institutional policies to support implementatione) EntertheCPGsaspartofthequalityassuranceprocessf) Include the progress of the process within the work agendas

42 Creationoftheinstitutionalimplementationteamanddefinitionofroles

An institutional team should be created to develop the implementation plan This team should consist ofamultidisciplinaryteamincludingstakeholdersfromalllevelsofparticipationandaccordingtothecontext of application of the CPG The institutions that have teams for the development of guidelines orprocessestoimprovethequalityofcarethefunctionsandrolesofimplementationcanbeaddedtothem

Theteammembersshouldincludebull GeneralCoordinatorassignedbythedirectivesoftheIPSandsupportedbytheopinionleaderand

coordinated by a facilitator Responsible for coordinating all the activities of creation and execution of the implementation plan and seeking leadership approval of activities

bull Facilitator will be responsible for supporting the various implementation activitiesbull Clinical opinion leaders within the institution (Head of area or Teacher)bull Patients or organizations that represent thembull Decision makers within the institution (health service managers)bull Representative (s) of the various professionals who provide care to patients

The team should have the support of the administrative management of the Health Provider Facility and create or adapt a space where the team can meet to make decisions and create an implementation plan

43 Elaboration of the institutional implementation plan

The elaboration of an institutional implementation plan is the central component of the CPG implementation process It contains the set of activities that must be followed to facilitate the gaining of skills by providers and patients in order to aid in clinical decisions guided by the CPG recommendations It includes the availability of resources to do so and the systematic use of these recommendations To havemorechanceofsuccesseveryactionandeverystepundertheplanmusthavearesponsibleperson assigned

Not all recommendations of a CPG can be implemented in all services The conditions and institutional dynamics institutional andsocial context thepresenceof barriersand facilitators the feasibility ofimplementing the recommendations theeconomic feasibilityandavailable resourcesamongmanyotherthingscanhinderorpromoteimplementationConsequentlythedesignofeachplanrequiresconsiderationoftheparticularinstitutionalaspectsandsotheselectionofthemosteffectivestrategiesbecomestheelementthatrequiresmostattention(24)


Here are the steps for the development of the institutional implementation plan

431 Selection of the Guideline to implementHealthfacilitiesshouldprioritizeoneormoreguidelinesiedefinewhichguidelineseachwillimplementconsidering as many epidemiological profile variables as possible such as characteristics of thepatientpopulationanddiseaseburdenneeds to improve thequalityofcaredecreasevariability inthemanagementorcostreductionandtherelevantrecommendationsshouldbeidentifiedforeachfacilityAccordingtotheinstitutionalconditions itmustdecidewhichoftherecommendationsoftheCPGshouldbeimplementedInallcasestheimplementationteamshouldhaveaclearunderstandingof current clinical practice to know which recommendations are already being implemented and which should be put into operation The chapters for implementation of each CPG have included the results of prioritization exercises for selecting key recommendations for implementation

Commonlyguidelineshaverecommendationscoveringvariouscaresettings(outpatientemergencyhospitalization surgeries lab) and therefore different clinical professionals and specialists (internalmedicineobstetricsandgynecologysurgeryetc)Theprocessof implementationplanningshouldidentify those services that will be involved their complexity and the population subject of careestimatingtheneedforhumanresources(quantityandquality)peopletocallandsizingtheoperationof the organization when the recommendations are implemented

432IdentificationofbarriersandfacilitatorsIn thecontextof implementationofCPGbarriersrefer to factorsthatmayprevent limitor interferewith the implementation of the recommendations made and their adoption by health professionals and patients Enabling factors are those that encourage or promote changes (25)

Barriers and facilitators relate primarily to characteristics of the guidelines to the beliefs attitudesand practices of health professionals and patients or to local and sector circumstances whereimplementationisstartedandismaintained(26)Someofthebarriersrelatedtotheseaspectsarelackofacceptanceoftheguidelinelackofknowledgeofitsexistence(conceptsanduse)lackofasenseofbelonging lackofknowledgeonthemethodologyandtheMBEThefollowingcanalsoinfluenceadherencetoguidelinesinformationoverloadlackofaccessresistancetochangelackofmotivationpoorexpectationofresultsthelackofsupportfrommedicaloradministrativeauthoritiesprocessesforprescriptionauthorizationthelackofresourcestrendsinclinicalpracticetheattachmenttopopularbelief and involvement of the pharmaceutical industry

TherearedifferenttechniquestoidentifybarrierstoCPGimplementationTheinstitutionalteamshouldselectthosethatbestfittheirsituationSomeofthesearementionedbelow(27)

bull Brainstorming professionals related to the implementation process generate lists of possiblebarriersthattheremaybeintheCPGimplementationintheirspecificcontext

bull Case Studythisisathoroughdescriptionoftheanalysisofapastsituation(previousimplementationexperience) It usually involves several data-collection methodologies




bull Focus groupsanoraldiscussionwithagroupofstakeholderswhohaveexperienceinimplementationUnlikebrainstormingthereisfeedbackandthematicanalysisoftheresults

bull SurveysinformationgatheredthroughastandardizedsetofquestionsTheycanbestructuredorsemi-structured

bull Nominal Technical GroupahighlystructureddiscussionamongagroupofpeoplewithsummarizedandprioritizedideasThebarriersareidentifiedthroughaniterativeprocess

bull Delphi technique iterativeprocess inwhichagroupof participantsgenerates information fromspecificsurveysprearrangedforthecontextoftheguideItidentifiesbarriersthroughaconsensusprocess

The main barriers to the implementation process in institutions providing health services are summarized inthefollowingtable

Table 1 Summary of barriers to the implementation processBarrier performance categories Type of barriers Examples

Innovation

Feasibility Credibility Accessibility Attraction

TheCPGscanbeconceivedasunreliableordifficulttousemainlythoserecommendationsthatrequirechangeinpracticeorbehaviormodification

Individual professional

Awareness Knowledge Attitude Motivation for changeBehavior routines

Cliniciansdonotagreewiththerecommendationshavenomoti-vation to change or do not feel preparedClinicians agree that no relevant outcomes were includedIt is likely that some professionals feel that adhering to a recom-mendation may mean an increase in their workload or may com-plicate the type of care offered

Patient

Knowledge Skills Attitude Adherence

Patients can expect certain services such as prescribing antibiot-ics for respiratory infectionsPatientsrsquo beliefs that contradict the recommendation

Social Context

Colleaguesrsquo opinionNetwork CultureCollaboration Leadership

Local leadersrsquo opinion can increase the use of less effective inter-ventionsThe guideline does not have the support of specialized associa-tions

Organizational Context

Personal careprocessesCapacities Resources Structures

Excessive paperwork or poor communication can inhibit the use of the new technologyFeatures inherent in the organizational structure of each institu-tionVariables such as time constraints for the implementation of wel-fare activities

Political and Economic Context

Financial arrange-mentsRegulations Policies

Resource allocation does not consider the implementation of certain recommendations

Implementation Process Implementation and assessment plan

No reminders were madeThe implementation plan did not cover all the basicsInadequatemethodofimplementationoruseofasinglestrategy

Quality of the Guideline Quality of the report No inclusion of a simplifiedversion

The guideline does not include all methodological aspectsDoes not include a management algorithmUse of a complex language

AdaptedfromGuidelinesforthedevelopmentofEvidence-BasedclinicalpracticeguidelinesMethodologicalManual(27)


433DefinitionofstrategiesanddisseminationactivitiesOncethebarriersandimplementationfacilitatorshavebeenidentifiedthemostappropriatedisseminationstrategiesareselectedaccordingtothepersonneltechnicalandfinancialresourcesThefollowingaresomeglobalstrategiestoconsider

Table 2 Strategies for dissemination of CPGStrategy Definition

Audit and feedbackIt is based on determining the way clinical performance is developed in certain health processes overaperiodoftime(forexamplefrommedicalrecordscomputerizeddatabasesorviewsofpa-tients)

Continuing Medical Education ThecontentofCPGoccursinvariouseducationalactivities(lecturesconferencesetc)

Electronic systems to support decision making

Computerized medical information for access at the time of decision making (eg for doubts in diag-nosticteststreatmentsormonitoringofcertaindiseases)

Only distributiondissemination

ItreferstotheprocessofinformationsharinginordertointroducetheCPGstosocietystakeholdersand potential users

Interactive educa-tional meetings The content of the CPG is introduced in interactive workshops (active participants)

Individualized educa-tional visits

Peopletrainedinthehealthcontextconductindividualizedandcustomizedvisits(ldquofacevisitsrdquo)withcliniciansintheworkplaceitselfusingdifferentapproachestolearning(egspecificclinicalcases)

Financial IncentivesItconsistsofprovidingdifferenttypesoffinancialincentivestocliniciansorpatients(egpaymentoffeesgrantsscholarshipsattendingcoursesconferencesormeetingsforcompliancewiththerecommendations in the CPG)

Contents of the guide

Thewaytheguidelineanditscontentsweredevelopedcaninfluencetheimplementationoftherecommendations Very complex guidelines are inversely associated with compliance Better com-pliance is also associated when they have been developed by credible organizations and with levels of evidence on which it relied

Local opinion leaders Professionalslocallyconsideredcompetentinfluentialandwithcommunicationskillsbytheirpeersare responsible for transmitting the contents of the CPG

Administrative Inter-ventions

They intend to ease or force changes in the clinical work of professionals to adjust them to the CPG recommendations(egtheneedforthepersonsrequestingdiagnostictesttobeexpertsratherthanbeingprimarycarephysicianscovenantsclinicalmanagementcontractsetc)

Mass mediaIt refers to the use of different methods of communication to reach large numbers of people in the generalpopulation(televisionradionewspapersbrochures)andothersItlacksastructuredplan-ning for implementation

Distribution of educa-tionalmaterials

PresentationofguidelinesonpaperelectronicpublicationsaudiovisualmaterialsorpublicationsinscientificjournalsbasedontheaudiencesoughttoreachThecostisrelativelylow

Multiple interventions It consists of combining multiple strategies

Interventions on organizations

Theyrelateforexamplewithchangesinthephysicalstructures(changesintheworkplacetechno-logicaladequacyofregistrationsystems)Itmayalsoinvolvethecreationofnewunits(unitsofpainetc)hiringprofessionalsspecificallyresponsibleforimplementingsomeoftherecommendationsorcreation of multidisciplinary teams




Strategy Definition

Specifictopatients Activitiesaimedspecificallyatpatients

Regulatory interven-tions

Theseinvolvechangingthebenefitsorcostsofahealthservicebyalaworregulation(egregula-tion of prices of drugs or other interventions)

Reminders It consists of interventions whether electronic or manual in order to alert the health professional to performaspecificclinicalactivity(egcomputerizedorpapernoticestocompleteitmanually)

Traditional education Thecontentof theCPGis introduced invarious traditionaleducationalactivities(ldquopassiverdquoornoninteractiveeducationdisseminationofinformationthroughconferenceswebsitesetc)

Development of guideline in consen-sus with user

Development of the guideline in consensus with the end user of the same

Adapted from Systematic review of CPG implementation strategies (5)

434 Selection of implementation tools VariousinternationalagenciessuchasNICEandSIGNhaveidentifiedtheneedtodevelopvariouskindsoftoolstosupporttheimplementationprocessTheseincludeformsdatabasesinformationsystemsbrochurestoolsettrainingsessionsandmoreThesetoolsshouldbespecifictoeachguidemustbedesigned and considered within the implementation plan and they must accompany the processes of diffusion and dissemination

TheMSPShasdevelopedawebplatformfortheintroductionofclinicalpracticeguidelines(httpgpcminsaludgovco)andotherusefulmaterials for their studyand implementationwhile the IETShasdevelopedatoolswebsiteforldquoImplementationSupportrdquothatcanbeaccessedbyenteringhttpwwwietsorgco

435DefinitionoftheincentiveplanAccording to institutionalpolicies the typesof incentives tosupport the implementation thatcanbepresentedtoguidelineuserswillbedefinedinordertoencourageitsuseandapplicationbasedontheassessment indicators

Anincentiveisastimulusthatwhenitisappliedindividuallyorganizationallyorinthesectoritmovesencouragesorcausesanaction(28)ItcanmeanabenefitorrewardoracostorpenaltyThestimulican have a positive character when they reward somebody that has shown the desired behavior or negative when they punish whoever deviates from this behavior In the Quality Assurance System in Colombiatheseincentivesforqualityimprovementareclassifiedasfollows(29)

bull ldquoPurerdquo economic incentivesthesearebasedonthefactthatqualityimprovementismotivatedby the possibility of financial gain Different countries use both positive and negative economicincentives


bull Prestige incentivesquality ismaintainedor improved inorder tomaintainor improve imageorreputationTheypossiblydonotgenerateextramoneybut rather the recognitionof friendsandstrangers and greater social acceptance

bull Legal Incentives the decline in the quality is discouraged through sanctions or rewards to thewinnersthroughsomelegalprivileges(taxadjudicationsinbids)

bull Ethical and professional incentives in the case of the provision of health services there areincentivesforimprovingthequalityofthesectororofanethicalandprofessionalnatureQualityis maintained or improved in order to comply with a responsibility to represent the interests of the patient

436IdentificationofresourcesneededforimplementationOncetheinstitutionalimplementationplanhasbeenbuilttheeconomictechnicalandhumanresourcesrequiredwillbeidentified

437 Preparation of the schedule of activitiesThe timeline allows for the adjustment of the activities in real time within the implementation plan It is important to identify those responsible for implementation

438 Selection of evaluation and control mechanismsA number of indicators must be selected in the process of implementing the CPGs in order to perform evaluationandmonitoringAsystematicreviewof implementationmodels(8) identifiedanumberofindicatorswhichwereclassifiedaccordingtowhethertheycorrespondtostructureprocessoroutcomeand if they will determine effectiveness or impact

Table 3 Indicators of the implementation processAssociated

factorsType of indi-

cator Effectiveness Impact

Provision of health services

StructureAdjustingthephysicalplantandacquisitionoftech-nologies needed for the interventions recommend-ed in the guideline for level of care

Increased coverage in rural areas andor vulnerable population

Process

Number of patients treated according to the CPG recommendations

Effective coverage with the CPG recommendations

Number of CPG recommendations included in the purchase and delivery of health services

Reduction of pocket spending for new health interventions

Results Identificationofclinicalbehaviorchangeintheman-agement of the particular health condition

Reduced mortality or number of complications by health condition

Financing

Structure Directcostsrelatedtohealthconditionmodifiableby the recommendation

Budget Impact of health care as recommended by CPG

Process Creatingfinancialprotectionfundsfortheimple-mentation of CPG

Price regulation of purchase and sale of health interventions

Results Financingofspecificinterventionsbyclinicalprac-tice guideline





Associated factors

Type of indi-cator Effectiveness Impact

Human re-sources

Structure Numberofhealthprofessionalsrequiredforoptimalservice delivery


Process Number of graduate health professionals and in trainingtrainedinCPG


Results Number of health professionals who provide health services as recommended by the CPG


Information Systems

Structure Inventoryofsuppliesresourcesandhealthinfor-mation processes Operating information system

Process Number of recommendations of each CPG included in information system

Regulationofcostsandqualityofhealth interventions

Results Number of institutions with CPGs incorporated into computerized medical history

Makingefficientclinicalandad-ministrative decision

AdaptedfromSystematicReviewModelsofImplementationofClinicalPracticeGuidelines(8)

44 Preparation of Baseline

Thebaseline is thefirstmeasurementofall indicators in the implementationplan itallowsknowingthevalueoftheindicatorsattheinceptionoftheprocessandthereforeidentifiesthestartingpointTobuildthebaselineitissuggestedtoconsideramongotherstheindicatorsintheCPGrelevanttotheinstitutionalsoprimarysourcescanbeused(owninformationofinstitution)foraclearunderstandingofcurrentclinicalpracticeorsecondarysources(MSPSresearchotherinstitutions)forinformationthat can be inferred to the institution

Theestablishmentof the linemustbemadebeforestarting the implementationactivities so that itcanbeuseful tomakecomparisons toassess thechanges thatare takingplaceandmeasure theachievement of objectives The baseline also eases programming activities necessary to comply withtherecommendationsestimatestheresourcesrequiredandprojectstheimplicationsincostororganizationalchangesIfthebaselineisnotestablishedoutcomeandimpactevaluationsmaylackreliability

45Practicalstepsindefiningtheinstitutionalimplementationplan

bull SelecttheCPGtoimplementTheimplementationteamwillidentifyaccordingtotheneedsofeachinstitutiontheimplementingguidelinesforclinicalpracticeTheMSPSportal(httpgpcminsaludgovco) includes CPGs developed for the Colombian SGSSS

bull Use a form to capture the institutional implementation plan (See Annex 2 Institutional Implementation Plan)

bull Identify recommendations to implement According to the institutional conditions which ofthe recommendations in the CPG should be implemented must be selected The chapters in


implementing each CPG have included the results of prioritization exercises that allow selecting key recommendations to implement

bull Identify barriers and facilitators to the implementation of selected recommendations Once therecommendationstobeadoptedineachIPSareselectedbarriersandfacilitatorsofimplementationareidentifiedTofacilitatethisprocesseachCPGcontainsgenerallistingsofbarriersandfacilitatorswhichmustbe reviewedandsupplementedwith thosespecific toeach institution (SeeAnnex3IdentificationofBarriersandfacilitators)

bull IdentifyresourcesandincentiveplanTheimplementationteamshouldidentifythefinancialhumanand technical resources necessary for the adoption of the recommendations to be effective In the ldquoSupport for the implementationrdquosectionof theIETSwebsite(httpwwwietsorgco)youwillfindtools produced for this purpose

bull Definetheschedulebull Conduct a follow up to the adoption of the recommendations The CPGs include a list of

indicators Developer groups and IETS suggest monitoring indicators aligned with the CPG tracer recommendations

46 Tips for creating the implementation plan (27)

The following are recommendations for the development of the implementation planbull Integrateanimplementationteamanddefineworkspacessolelydedicatedtoconsideringissuesof

implementationbull Try to link the patients or their perspective through representatives at all levels of generation of the

planbull Plansinceinceptiontheconsiderationsofdiffusiondisseminationandimplementationanddiscuss

them at each meeting of the guide Progressively increase the space devoted to the discussion and agreement of these aspects

bull Performaproperdiagnosisoftheimplementationcontextcharacterizingtheusualpracticethegapbetweenthisandtherecommendationsoftheguidetheorganizationalculturalsocialeconomicandmarketfactorsuserpreferencesmediabroadcastingavailableandtheireffectivenessinthecontext

bull Adjust the guideline to the context of implementationbycomplexity resourceavailabilityusersneeds and dissemination tools Do not be afraid to trim aspects that are not relevant to each institution

bull Choose strategies with teaching components in real scenarios Integrate the planned activities according to the expectations thereof in the cycle of awareness-agreement-adoption-adherence

bull Link theguidelineasatoolforqualityoftheauditandcontinuousimprovementprogramsbull Choosefreeaccessstrategiesinbothphysicalandelectronicmediaaswellastheuseofclinical

pathwaysbull Pinpoint the Heads of each level of diffusion and implementation and attempt to provide the

strategies suggested to achieveeachobjective and the indicators to evaluateToRemember topresenttheplanforassessmentbythepotentialstakeholdersotherdevelopersandthoseinvolvedin its implementation

bull Usematerialstosupporttheimplementationoftheguidelines(mediaeducationsupportindecision-making)thisisthecaseofmediastrategieschecklistselectronictoolsflowchartsetcTheIETS




hasdevelopedasectionldquoSupportforImplementationrdquowhichcanbeaccessedthroughthenetwork (httpwwwietsorgco)

bull Conduct a pilot of the diffusion and implementation of the guideline using the tools developed Seek feedback from potential users and experts in the area

bull Remember that the implementation is a continuous and adjustable process and does not end until the guideline becomes obsolete or removal is decided for other reasons

bull Choose the best indicators depending on their availability and relation to the important aspects of theplanningoracceptanceoftheguidewithoutexceedingthecapacityandresourcesavailable

5 Phase 2 realization ofimplementation activities


Phase2realizationofimplementationactivities

This phase is designed to effectively translate the recommendations raised in the CPG to the work of everyday practice This involves making changes or modifications in the provision of servicesparticularlyintheofficeorotherhealthcareactivitiesAsageneralrequirementforimplementationtheCPGsshouldproposetheirrecommendationsbyconsideringtheglobalframeworkofimplementabilityiebyfavoringcharacteristicsthatincreasethelikelihoodofbeingputintopracticebyendusers

By implementing the recommendations of a CPG the implementation plan must be developedsystematicallyThisrequiresinvolvingstrategiestoreduceresistancetochangewhilecombiningthedecisionsofadministrativefinancialandeducationalnaturethatareeffectiveinpractice(30)Toachievethis it is important that the institutional teamformagroupthataccordingto the levelof institutionaldevelopmentandresourcecapabilityhas thesupportofcommunicationsexpertsandprofessionalsperformingfieldwork

This team should have available

bull A directororcoordinatorassignedateachinstitutionforhisorherleadershipwhoshouldorganizemeetings to identify barriers and in turn plan and generate commitment among stakeholders to overcome the identifiedbarriersThispersonmustalsopromote theeffectiveparticipationof thevarious actors to promote favorability of the environment where the CPG is being implemented

bull CommunicationConsultantspreferablyprofessionals insocialcommunicationorsocialscienceswithexperienceinmanaginggroupprocessestransferdiffusionanddisseminationofinformationTheir primary responsibility within the team is to identify and use the institutional opportunities for diffusion of guidelines

bull Clinical and administrative staff of the various institutions involved in the implementation process Their role is to support the process of identifying barriers and plan the strategies to overcome them

bull Audit Coordinators Their primary function is to monitor processes to ensure that each recommendation receives adequate support to facilitate implementation and in turn regularly collect and analyzeinformation necessary for the construction of indicators for monitoring and evaluation of CPG performance

Finallyitis necessary to involve the team representing CPG end users For this it is important to identify wellthedifferenttypesofrecipientstowhomtheCPGshouldbedisseminatedtoselectproperlythestrategies to use in the wide range of possibilities

CPG end users must be represented by the clinicians who will use the recommendations made in the sameCPG(generalpractitionersmedicalspecialistsandhealthprofessionalsingeneral)officialsandstaff of health institutions and patients

The main function of the representatives of the end users is to aid in the identification of barriersand the selection strategies to overcome them and support the team coordinating the implementation strategy in the selection and adaptation of the approach and messages to disseminate according to the particular characteristics of each application environment



According to theCochraneEffectivePracticeandOrganizationofCaregroup(EPOC)interventionsaimedatovercomingthebarrierscanbesummarizedinthefollowingaspects

Table 4 Summary of interventions to overcome barriers

Interventions on profes-sionals

- Distribution of educational materials- Training sessions- Local consensus processes- Visits of a facilitator- Participation of local opinion leaders- Patient-mediated interventions - Audit and feedback- Use of reminders- Use of mass media

Financial interventions - Professional or institutional incentives - Incentives for patients

Organizational interven-tions

These can include changes in the physical structures of the health care units in medical record systems or ownership- Aimed at professionals- Aimed at patients- Structural

Regulatory interventions

Any intervention that aims to change the delivery or the cost of health care by law or regula-tion- Changes in the responsibilities of the professional- Management of patient complaints- Accreditation

Incentivesmaybepositive(suchasbonusesorpremiums)ornegative(suchasfines)AdaptedfromEffectivePracticeandOrganizationofCareGroup(EPOC)httpwwwepoccochraneorg

The review of the evidence to determine the effectiveness of different methods of implementing CPG foundthatsomestudiesdosogloballywithoutclassifyingbydiffusiondisseminationorimplementationstrategiesAsystematicreviewof235studies(31)showedmorepertinentfindings

bull 866ofthestudiesshowedimprovementinpracticeasaresultoftheimplementationprocessesalthough the effect was variable and it depended on the type of comparison and study done

bull ImplementinginterventionsthataremostoftenevaluatedareremindersystemseducationalmaterialsauditandfeedbackAbeneficialeffectwasfoundforallofthemalthoughsmallormoderate(141forreminders81foreducationalmaterials7forauditandfeedbackand6forinterventionswith multiple strategies) The maximum effects seldom exceed 25 of absolute improvement

bull Reminder systems are interventions individually shown as the most effectivebull Althoughmultiple interventionsappear reasonablymoreeffective theyarenotnecessarilymore

effective than single interventionsbull Educationalmaterialshavelittleeffectivenessbutpotentiallycanhavesignificanteffectsandwith

relatively low costbull Moreresearchisneededinthisfieldmainlyinaspectsrelatedtotheoreticalmodelsofbehavior

changeandefficiency

6 Phase 3 implementation monitoring and follow-up


Phase3implementationmonitoringandfollow-up

OncetheCPGsareimplementedtheprocessofevaluationandmonitoringwillbeginThiswillshowthebenefitsandchallengesandwilldeterminetheneedforadjustmentsormodificationstotheprocessThe application of the guidelines should result in improvements in the quality of care for patientsHoweverconsideringthedifficultiesofinterpretingdatafrompatientsinacommunityfocusingontheevaluationofoutcomesofpatientsonlyasameasureofsuccessof theguideline is insufficientandimpractical

In order to make the best decisions in terms of effectiveness of CPG according to each particular contextseveralfactorsmustbeconsideredtoassessbull WhatarethelikelybenefitsandcostsrequiredforeachimprovementstrategyThelikelihoodofthe

effectivenessofdisseminationandimplementationstrategiesfortheidentifiedconditionshouldbeconsideredalsofortheresourcesrequiredtodevelopdifferentstrategies

bull Whatare the likelybenefitsandcostsasa result ofanychange inproviderbehaviorDecisionmakersneedevidenceontheeffectsofspecificstrategiesforimprovingthequalityandresourcestodevelopthemandhowtheeffectsofthestrategieschangeaccordingtofactorssuchascontextuserandbehaviorchange

61 Monitoring

Inordertoevaluatetheimpactofimplementationstrategiesitisnecessarytoknowtheleveloffamiliaritythat has been achieved with the guideline and the current usage It is appropriate to collect data on the traditional use of resources and changes in clinical outcomes Ideally the assessment should be included in the implementationplan so that it guides thedeterminationof thebaselineandallowscomparison of before and after

EachorganizationhasspecificorganizationalstructuresandpoliciesEachareaisexpectedtoconductits ownassessment by reviewof an assessor groupAlso external reviewersmust be included tovalidate the assessment if and when possible

Theresponsibilitiesoftheevaluationgrouparebull Collection of measurementsbull Identificationofindicatorswithmethodologicaladvicebull Analysis of resultsbull Socialization and dissemination of resultsbull Preparation of a report containing relevant interventions to improve adherence to recommendations

62 Evaluation plan for implementing CPG

When creating the evaluation plan the following questions should be addressed (27)bull Howwillitbeknownwhethertheguidelinesarereceivedreadusedevaluatedlocallypromotedor

acceptedlocallybull Whatmethodsare required toevaluate theaboveQuestionnaires surveys case reviewcyclic

criteria based on audits and routine monitoring



bull Whatknowledgegapshavebeenidentifiedthroughtheassessmentbull Howwilltheresultsoftheevaluationbefedbacktothoseresponsibleforimplementationbull Howwillchangesbeidentifiedandimplementedineachstepofthechainbull IsthereaclearmethodofevaluationExplicitoutcomesthatcanbeevaluatedlocalstandardsof

theguidelineskeyindicatorstogiveameasureofimplementationbull Whatisthemostimportantexpectedoutcomeandhowitwillbemeasuredbull Who should evaluate the guideline Clinical leaders in the local context managers external

organizationsauditstructuresbull HowoftenisassessmentdoneTheevaluationoftheimplementationoftheguidelinesshouldbe

performedat leastonceevery threeyearsbut inareaswherechangesaremademorequicklyevaluationwillbemorefrequent

FurthermorethetypeofevaluationtobeperformedshouldbedefinedThismaybebycomparison(forexampleif theservicehasimproved)orabsolute(egwhether ithasreachedapredeterminedstandard)

WithregardtothetypesofdesignforassessmentsthemostcommonassessmentsarebeforeandafterstudiestimeseriesqualitativeandeconomicevaluationsInordertoidentifytheeffectsoftheinterventionitbecomesnecessarytoperformcontrolledassessments(CA)TherearefewCAsandtheneedformorestringentefficiencyandeffectivenessassessmentshavebeenidentified

621 Components of the evaluationTheevaluationoftheeffectsoftheguidelinehassixcomponentsbull Dissemination of the guidebull Whether clinical practice is aimed at the CPG recommendationsbull Whether health outcomes have changedbull Whether the CPG has contributed to any changes in clinical practicebull Impact of CPG in the knowledge and understanding of usersbull Economic evaluation of the process

63 Feedback and adjustments to the implementation plan

Based on the evaluation results the implementation team should review whether there arerecommendations those have not been adopted and evaluate the reasons why they were not put into operation in the IPS It should then evaluate a change in implementation plan strategies to improve adherence to the CPG recommendations

7 Implementation ofpatient guidelines


Implementation of patient guidelines

The CPGs for the SGSSS in Colombia include a version for patients and caregivers they provide informationontherecommendationsofaspecificguidelinetoclinicalpracticeinaneasilyunderstandablelanguageAdditionallytheyareintendedforpatientstounderstandmedicaldecisionsandimprovetheiradherence to recommendations

The Patient Guidelines should be easily accessible to any citizen interested in the subject Implementation is mainly based on diffusion and dissemination strategies

It is recommended that each of the institutions identify the diffusion and dissemination strategies aimed at patients and caregivers A key point for the CPG implementations is that the people involved have accesstotheinformationThiscanbedistributedinprintelectronicoraudio-visualmaterialsItmustbecompleteeasilyaccessibleandshouldbeavailablewhenneededHereisalistofmediathatcanbe used to distribute information Use several of them to obtain a better result

bull Internal communication media welcome manual voice communications billboards circularslettersandotherdocuments internalpublications(magazinesnewslettersbrochures)corporatecommunication channel (intranet)

bull ExternalmediaMinistryofHealthplatformemailtextmessagesbull Customcommunicationmediaspecificprogramsmeetingswithleaderssurveysinternalevents

videoconferences

Annexes


Annex 1Comprehensive implementation model of clinical practice guidelines



Date

Institution

Name of the Clinical Practice Guideline

Reason for the choice of the guideline

Relationship to existing policies or clinical practice guidelines implemented in the institution

Members of the institutional implementation teamName Position in institution Office Role

Selection of the recommendations to implementThe team should review the CPG recommendations that should be implemented when findingdifferenceswiththecurrentpracticeoftheinstitutionFirstchecktherecommendationsprioritizedbythe Developer Group

Annex 2Institutional implementation plan


Annex 2 Institutional implementation plan

Number Recommendation

1

2

3

4

5

6

7

8

Barriers and facilitators to the implementationReview relevant section of the manual and identify which barriers and facilitators correspond to the recommendations to implement

Recommendation

Barriers to implementation Facilitators

Recommendation


Recommendation




Select the strategies for implementing the clinical practice guideline and patient guideline that adjust to context (See manual for selecting strategies)

Review relevant section of the manual and identify implementation strategies which can be applied in the institution

Steps for adoption of the recommendations Identify the activities that should be developed in the IPS

Activity (data collection training development of forms acquisitions etc) Responsible Start date End date

Educational and dissemination strategies

Who are educationalstrategies aimed at

What informationis needed When do they need it Who will provide

the information


Estimated time and resourcesResources (human technical economic) Estimated value (hours or money)

Approval by the appropriate level of managementName Approval Date of application Date of approval

IndicatorsMeasurement Date

Indicator Numerator Denominator Source Number




Annex 3Identifier of barriers to implementation

Barriers Observation Present Strategy to overcome

Concerning the CPG

Evidenceinsufficienttosupportallrecommendations YES NO

Completeguidelinethatistoolongwhichcouldencouragethereviewof only the summary guide YES NO

Thepublishingformslimittheirfrequentconsultation YES NO

Final recommendations may present ambiguity in their interpretation by general practitioners YES NO

The references are not easily accessible to the public user of the CPG YES NO

Con

cern

ing

prof

essi

onal

s

Ignorance of the existence of the guidance and evidence based med-icine YES NO

Limited knowledge to interpret scientific literature little awarenessofnegativeoutcomesinpracticenotallhaveInternetaccessintheworkplace

YES NO

Continuous training and updating in the hands of the pharmaceutical industry YES NO

Resistance to change and fear of facing medical-legal problems YES NO

Consideration of scientific information as invalid or irrelevant poorqualityofscientificconferences YES NO

Lack of peer support and poor teamwork YES NO

Perception that CPG does not apply to most patients or in all IPS YES NO

Excessive demand for care whichmakes it difficult to spend timereading guidelines YES NO

Concerning social con-text

Someprofessionalsarestrongly influencedby theviewsofopinionleaders unfavorable to guidelines YES NO


Annex3Identifierofbarrierstoimplementation

Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt

Public policies related to health care model focused on health as a profitableservicefortheinsurerandnotasacivilright YES NO

The shortcomings of the enabling system and control of health care providers (IPS) YES NO

The lack of a networking organization of health care providers limits the reference and counter-reference system and accessibility to ser-vices

YES NO

AbsenceofnationalimplementationplanoftheCPGsstructuredac-cording to the degree of development of IPS and taking into account theprioritizationcriteriaoftheguidelinesandthedeadlineforthis

YES NO

Improper operation of the information system YES NO

Limited leadership of those responsible for the IPS YES NO

IPSwithlimitedhumanphysicalandfinancialresourcestoimplementthe CPG-SCA YES NO

Few IPS accredited or in accreditation process YES NO

Poor management and poor hospital policies oriented to SOGC and the development and implementation of the guideline YES NO

Lack of incentive system to IPS and health professionals involved in implementing CPG YES NO

Ignorance of the costs and funding sources for the CPG implemen-tations YES NO

Other Bar-riers

YES NO

YES NO



Annex 4Tools and resources for implementation

Tools and resources for implementation are a set of supports to the various activities to be undertaken duringtheimplementationprocessTheycanprovidetheoreticaltechnicalandpracticalcontributions

CurrentlywehavemultipleportalsonthewebthroughwhichwecanaccessbothCPGandtoolsandresourcesforimplementationSomeofthemareasfollows

National portalsMinistry of Health and Social Protection gpcminsaludgov Institute of Health Technology Assessment wwwietsorgcoAlianza CINETS wwwalianzacinetsorgNational Cancer Institute wwwincancerologiagovco

International portalsAHRQ wwwinnovationsahrqgovGIRAnet wwwgiranetorgGuiasalud wwwguiasaludesNational Guideline Clearinghouse wwwguidelinegovNew Zealand Guidelines Group wwwhealthgovtnzNICE wwwniceorgukSIGN wwwsignacuk

41 CPG Versions and forms for SGSSS in Colombia

To facilitate access to information for different target populations CPG documents for SGSSS inColombiaarebuiltindifferentversions(fullversionshortversionorsummaryandinformationdocumentforpatientsrelativesorcaregivers)andbothinprintedformsandelectronic

InthefullversionoftheCPGanimplementationchapterisincludedwithexcerptsofidentificationofbarriersalternativesolutionsandfacilitatorsLikewiseinthenewestCPGprioritizationexerciseshavebeen included of recommendations made by the GDG

42 Stages of Change Model

Resistance to change is one of the fundamental problems during the CPG implementation process OneofthemostfrequentlyusedapproachestointerpretthisbehaviorandinterveneinitisthemodelofstagesofchangeproposedbyProchaskaandDiClementeInthisbehaviorchangeisconsideredaprocessandnotaneventThuswhenapersonmakesachangeofbehaviorthepersonmaygothrough


Annex 4 Tools and resources for implementation

fivestageseachofwhichhasdifferentneedsandstrategiestopromotechangeprecontemplationcontemplationpreparationactionandmaintenance

Theory of stages of change adapted to the process of CPG use in clinical practice of health professional

Stage Definition Strategies for change Priority educational activities to promote change

Pre-consideration

(Referring to as-sertion A of the CPG Survey)

The health profes-sional has no inten-tion to implement the CPGs in the clinical practice

Identify the reasons why the health pro-fessional has no intention to implement the CPG

Show the importance of implementing CPGs in clinical practice

Provide information about the risks and benefitsoftheapplicationofCPG

We recommended prioritizing the fol-lowingobjectives minus Presentthebenefitsofevi-dence-based medicine and the CPG implementation

minus Knowbeliefsvaluesandopinionsofhealth professional on CPG

minus Identify barriers to implementation and propose solutions

Consideration

(Referring to as-sertion B of the CPG Survey)

The health profes-sional is consid-ering applying the CPG in the clinical practice in the fu-ture

Provide information on the benefits ofCPG implementation

Promote the implementation of a plan of action

Present the CPG recommendations and how to apply them in clinical prac-tice

We recommended prioritizing the fol-lowingobjectives minus Present the CPG to health personnel

minus Develop a group action plan for CPG implementation

minus Establish an individual commitment to implementing the CPG recommen-dations

minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations

minus Choose the appropriate course of action for clinical case

Preparation

(Referring to as-sertion C of the CPG Survey)

The health profes-sional decided to apply the CPG in the clinical practice and is preparing for it

Assist the health professional in devel-opingaspecificactionplan






minus Choose the appropriate course of action for the clinical case




Action

(Referring to as-sertion D of the CPG Survey)

The health profes-sional has been using the CPG in the clinical prac-tice less than six months

To assist the health professional in im-plementing the CPG recommendationsProvide feedback to the health pro-fessional about changes to the clinical practice

Provide activities to strengthen the CPG implementation

We recommended prioritizing the fol-lowingobjectives minus AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinical situations


minus Recognize barriers and needs en-countered in the CPG implementa-tion and discuss possible solutions

minus ReflectontheprocessofCPGimple-mentation

Maintenance

(Referring to as-sertion E of the CPG Survey)

The health profes-sional has used the CPG in the clinical practice for over six months

Provide feedback to the health pro-fessional about changes to the clinical practice

Provide activities for strengthening and update

We recommended prioritizing the fol-lowingobjectives minus ReflectontheprocessofCPGimple-mentation

minus Present the results of the implemen-tation plan

minus Reflectontheresultsoftheindica-tors

43 Learning Strategies

The main learning strategies that can be selected for the educational activities in implementation programsare

1 Strategies for reproduction of knowledge

minus Repeat the text orally

minus Create analogies and metaphors

minus Use mnemonics

minus Summarize the text

minus Create mental images

minus Replyandcreatequestions

minus Paraphrase

minus Teach others

minus Associatetheknowledgewithotherspreviouslyacquired

minus Apply knowledge to new situations in the subject being studied 2 Strategies for organization of knowledge

minus DesigntablescomparisonmatricessummarytablesVenndiagramstime-linesgraphsflowchartsmindmapsconceptmapsfreepatternsamongothers


3 Strategies for self-evaluation and self-regula-tion

Planning Strategies minus DefinelearninggoalsinCPG

Monitoring strategy minus To assess the understanding of the content of the CPG

minus Identify strengths and weaknesses in the CPG

minus AssesstheextentoffulfillmentofeducationalgoalsandindicatorsoftheCPG

Executive control strategy

minus Devise corrective if indicators or targets were not achieved

Strategies associat-ed with motivation

minus Specifyexternalreasons(bettercareawardsetc)andinternal(tolearnmorejobsatisfactionetc)

Evaluate the expec-tation of successfailure

minus Definehowsuretheyareaboutlearningmoreandperformingthelearningactivity of CPG

Assess the emo-tional and attitudi-nal factors

minus DefinestereotypesandemotionsthathinderlearningorapplicationoftheCPG

4 Management of contextual factors

Time Management minus Assess the timing and planning for the study and CPG implementation

Physical environ-ment for learning

minus Chooseanappropriateplaceinrelationtoventilationlightcomfortandpriva-cy for the study

Definesupportstrategies

minus Ask others for help

minus Usechatroomslibrariesresourcesgroupsorotherstrategiestoincreasethepossibilityofsupporttounderstandatopicifthisisrequired

5 Management of educational re-sources

minus Use the Ministry of Health and Social Protection platform

minus Use the full CPG as a consultation document

minus Use the CPG for Health Professionals

minus Use Guideline for Patients and Families

minus Usetheresourceslistedintheplatform(graphicstablesandalgorithms)6 Strategies for critical thinking minus Assess the CPG

minus Compare the CPG recommendations with their prior knowledge and assess differences between their practice and what is reported in the CPG

minus Askconstantquestionsabouttheimprovementofcareforourpatients




44 Teaching techniques to support implementation

Theteachingtechniquestosupportimplementationthatcanbeselectedareasfollows

Teaching technique Objectives and process Resources Advantages Recommendations

Confe-renceLecture

Oral presentation of a topic logi-callystructuredmadebyaphysi-cian to a group of people

minus Room

minus Boardflip-chart or overhead projector

minus Sound

minus PowerPoint Presentation

minus Ideallyase-nior lecturer on the sub-jectopinionleader

It is an inex-pensive way to commun ica te informationSuitable for large groups of people

Present the information in an orderly manner and emphasize the most im-portant aspects

Use visual aids to capture the audi-encersquos attention and facilitate learn-ing

Avoid lectures over 45 minutes to pro-vide the audience the assimilation of information

Use examples and case studies to keep the concentration of the audi-ence

Encourage audience participation throughquestionstoavoidadoptingapassive attitude

Case study

(cases fo-cusing on the critical a n a l y s i s of deci-s ion-mak-ing)

The aim of this type of case study is for participants to analyze the decisions made by another indi-vidual during the care of a patient

Theactivityhas3phases

Individual assessment of patient management case

Analysis and group discussion of the case and the consequencesof the decisions taken during han-dling

Development of a management proposal based on the CPG rec-ommendations

minus Room that allows small group work

minus Board or flipcharttorecord the contributions of the partici-pants

minus Ideallyanexpert opinion leader to lead the activity

minus Educational materials (writing of the caseCPG)

Encourages crit-ical analysis of decision-making in actual clinical situationsP r o m o t e s knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclin-ical situationPromotes ac-tive participa-tion which fos-ters meaningful learning

Select a real case that has been treat-edat the institution inorder tohaveaccess to full information

Choose a case that represents a sit-uation of complex decision making addressed b CPG

Avoid mentioning the names of the people who handled the case

From themedical records write theeventso thatparticipantshavesuffi-cient information on patient character-isticsandonthesequenceofactionstaken by the person who assisted the patient

Before the activity prepare the pos-sible course(s) of action proposed by the CPG to operate the selected case

Duringtheactivitymakesurethatallattendees participate and be espe-cially careful with time management


Case study

(cases fo-cused on creating proposals for deci-sion-mak-ing)

The aim of this type of case study is for participants to assess a case and raise the appropriate course of action for management


minus Individual assessment of the case and proposed manage-ment options

minus Analysis and discussion in group of proposed manage-ment options

minus Develop a management pro-posal based on the CPG rec-ommendations




minus Educational materials (caseCPG)

Encourages critical analysis of real clinical situations

Promotes knowledge of some of the CPG recom-mendations and its application to decision making inaspecificclinical situa-tion

Promotes active participationwhich fosters meaningful learning

Choose a case that represents a situation of complex decision making addressed by CPG

Providesufficientinformationtoallowparticipants to make a comprehen-sive diagnosis of the clinical condi-tion of the patient

Beforetheactivitypreparepossiblecourse(s) of action proposed by the CPG to operate the selected case


Prob-lem-Based Learning

A small group of people (6-8) meetswiththehelpofatutortoanalyzeandsolveaspecificprob-lemdesignedtoachievespecificlearning objectives

The problem is a starting point for the participant to identify learning issues needed (knowledge and skills) for study


minus Presentation of the problem

minus Identificationoflearningneeds

minus Search and ownership of infor-mation

minus Resolution of the problem and identificationofnewproblems



minus Availability of bibliographic resources

minus Ideallyhavea computer with internet access

It allows partic-ipants to make a diagnosis of their own learn-ing needs

Promotes active participationwhich promotes meaningful learning

It stimulates self-learning


Fosters the development of interpersonal skills

Prepare the problem Do not forget that this includes one or more guid-ingquestionsandlearningobjectivesproposed

Submit the problem to the partici-pants prior to the activity in order to becomefamiliarwithitandfindtheinformation they deem relevant for group work

Duringtheactivityaskquestionsthatencourage participants to evaluate different perspectives on the problem and develop critical thinking skills

At the end of the activity make a group feedback and present the problem that you have prepared for the next meeting




Educational workshop

Working meeting in small groups that aims to develop a practical learningthatresultsinafinalproduct

The activity is to make a group reflectionaboutatopicclinicalcaseorguidingquestionandprepare a document summarizing thecontributionsagreementsoraction plans that are developed during the meeting



minus Paper or computer to prepare the finaldocu-ment

Stimulates the expression of beliefsvaluesopinions and experiences of the participants

Promotes dia-logue among participants


Allows group development of afinalproduct

Preparethesubjectclinicalcaseorguidingquestionoftheworkshop

Duringtheactivityencouragepartici-pantstoexpresstheirbeliefsvaluesopinions and experiences on the proposed topic

Promote the participation of all at-tendees

Notethereflectionsanddiscussionsof the participants These serve as inputforthepreparationofthefinaldocument

Be very careful with time manage-ment to achieve all the objectives oftheworkshopespeciallythefinaldocument

Simulation In a simulated environment par-ticipants apply their knowledge to develop practical skills for action ordecisioninspecificsituations

Theeventhas4phases

Organization of the simulated clin-ical case or scenario

Familiarizing participants with in-structionsmaterialsorequipmentin the simulation scenario

Interaction with the situation par-ticipants to act or make decisions

-Evaluation Of simulation results andpracticalskillsacquiredbyparticipants

minus Physical space suit-able for simu-lation

minus Peoplema-terials and equipmentre-quiredforthesimulation

Allows the de-velopment of skills for CPG implementation recommenda-tionsinspecificclinical situa-tions

Avoids the risks of training in real clinical settings

Encourages the development of behaviors and attitudes

Prepare the clinical case or situation to be simulated This includes the in-structions to be given to participants

Plan the development of the activity Consider both the physical space suchaspeoplematerialsandequip-ment

After introducing the participants to thesimulatedscenariotherulesandinstructionstobefollowedobservetheir performance

Attheendoftheactivitystimulatereflectionabouttheexperienceandprovide feedback on performance of participants taking into account the CPG recommendations for the partic-ular clinical situation

45 Educational strategy for the implementation of CPG

There are educational guidelines to support the implementation that allow the design of activities to facilitatetheimplementationprocessAmodelisasfollows

First educational activity (90 minutes)The main objective of this activity is to present the CPG that is considered for implementation The use oftwoteachingtechniquesisrecommendedinthisactivitylectureandeducationalworkshop


Objectivesbull Present the CPG to health personnel

- KeyCPGrecommendations(strengthofrecommendationqualityofevidencepointsofgoodclinical practice)

- Flowcharts covered by CPG for the management of patients- Benefits and limitations of the CPG implementation (for patients clinical practice health

personnel and the institution)bull Discuss the CPG recommendations and express the beliefs values and opinions of health

personnel in relation to thembull Establish an individual commitment to implement the CPG recommendations in clinical practice

Before the activitySummon the people involved in the process of CPG implementationInviteaskilledprofessional to introduce theCPG tohealthpersonnelTosupport thepresentationuse the audiovisual material available on the platform of the Ministry of Health Make sure you have adequate physical space for attendees to be comfortable and for audiovisual aids to bepresentedproperly

During the activityTake feedback from the previous educational activity (5 minutes)Perform the lecture on the CPG to be implemented (20 minutes)Considerallowingtimetoanswerquestions(15minutes)Toconclude theworkshopprovide feedbackwith theagreements reachedby theparticipantsanddetermine with each an individual commitment to implementing the CPG recommendations in clinical practiceMake clear the date and time of the next activity and specify the materials to be prepared for that meeting (5 minutes)

After the activityWrite a document that summarizes the key points discussed and action plan developed during the meeting Address it to the participants through a customized distribution medium

Second educational activity (80 minutes)This activityrsquos main objective is to make practical application exercises of the CPG Several sessions may be needed to cover the most important aspects of the guide For this activity it is recommended to use the teaching technical of case study or simulation




Objectivesbull Know and understand the main CPG recommendationsbull KnowandunderstandtheflowchartpresentedintheCPGbull AcquiretheabilitytoimplementtheCPGrecommendationsinspecificclinicalsituationsbull Conduct a critical evaluation of a real or simulated clinical casebull Ask and discuss options for handling of the casebull Choosethemostappropriatecourseofactiontakingintoaccounttheparticularcharacteristicsof

the case and the CPG recommendations

Before the activitySummon the people involved in the process of CPG implementationMake sure you have adequate physical space for work in small groups and have the necessarybibliography for consultation during the case discussion (CPG)Write the clinical case or set the stage for the simulationIfthefollowingeducationalactivityrequiresparticipantstopreparesomeeducationalmaterialprepareit and have it available to deliver during this meeting

During the activityTake feedback from the previous educational activity (5 minutes)Introducetheobjectivesoftheactivityandexplainthedynamicsoftheeducationaltechniqueselectedto perform it (5 minutes)Developtheselectedteachingtechnique(casestudiesorsimulation)(60minutes)

Third educational activity (80 minutes)Thisactivityrsquosmainobjectiveismonitoringusinggroupreflectionontheprocessofimplementation

Objectivesbull Monitor the CPG implementation processbull Recognize barriers and needs encountered during the CPG implementation and discuss possible

solutionsbull Evaluate the implementation plan developedbull Monitor the personal commitment of health professionals on the implementation of the CPG

recommendations in their daily clinical practice

Before the activitySummon the people involved in the process of CPG implementation


During the activityTake feedback from the previous educational activity (5 minutes)Introduce the objectives of the activity and explain the dynamics of the educational workshop (5 minutes)Conductaneducationalworkshop(60minutes)wherehealthprofessionalscanexpressthebarrierschallenges and perceived needs for the CPG implementation and propose solutions Based on the abovediscussiontheymayassessthegroupactionplanandmaketheappropriatemodificationstomake it more effective

After the activityWrite a document that summarizes the key points discussed and the action plan amended at the meeting Send it to the participants through a customized distribution medium

Fourth educational activity (80 minutes)This activityrsquos main objective is to critically evaluate the implementation process For this activity it is recommendedtousetwoteachingtechniqueslectureandeducationalworkshop

Objectivesbull Conduct an assessment of the CPG implementation processbull Present the results of the implementation plan to date

- Schedule of activities performed- Difficultiesencounteredduringtheprocess- Proposed solutions and results- Indicators of adherence to the CPG

bull Reflectontheresultsoftheindicatorsbull Establish key points for the continuation of the implementation plan

Before the activitySummon the people involved in the process of CPG implementationMakesureyouhaveadequatephysicalspacetodevelopthesuggestedteachingtechniquesPrepare a report on the CPG implementation process at the institution Include the schedule of activities undertaken difficulties encountered during the process the proposed solutions and results andindicators of adherence to the CPG Evaluate these indicators

During the activityTake feedback from the previous educational activity and present the objectives of the session (5 minutes)Hold a conference to present the report on the CPG implementation (20 minutes) Make special emphasis on the analysis of indicators




Conduct an educational workshop (50 minutes) where health professionals can meet and discuss clinical cases selected for analysis of adherence to the CPG recommendationsWhenfinished take feedback from theactivityanddeliver thematerial tobeprepared for thenextsession (5 minutes)

After the activityWrite a document that summarizes the key points discussed and the schedule for the continuation of the implementation plan


1 IOM (Institute of Medicine) 2011 Clinical Practice Guidelines We Can Trust Washington DC TheNational Academies Press

2 GrimshawJEcclesMThomasRMacLennanGRamsayCFraserCValeLTowardevidence-basedquality improvementEvidence (and its limitations)of the effectiveness of guideline dissemination and implementation strategies 1966-1998J Gen Intern Med200621(Suppl2)14-20

3 McGlynnEAAschSMAdamsJKeeseyJHicksJDeCristofaroAKerrEAThequalityofhealthcaredelivered to adults in the United States N Engl J Med20033482635-2645

4 Francke AL Smit MC de Veer AJE MistiaenP Factors influencing the implementation ofclinical guidelines for health care professionalsAsystematic meta-review BMC Med Inform Decis Mak2008838

5 Torres M Pinzon C Gaitan H Pardo R GrupoCochrane de Infecciones de Transmision SexuaAlianza CINETS Revision sistematica de Estrategias de implementacion de guias de practica clinica Actualizacion en Proceso de publicacion

6 Grol R Grimshaw J Research into practice IFrom best evidence to best practice effectiveimplementation of change in patientsrsquo care Lancet 20033621225ndash30

7 Ministerio de la Proteccioacuten Social ColcienciasCentro de Estudios e Investigacioacuten en Salud de la Fundacioacuten Santa Fe de Bogotaacute Escuelade Salud Puacuteblica de la Universidad de Harvard Guiacutea Metodoloacutegica para el desarrollo de Guiacuteas de Atencioacuten Integral en el Sistema General de

Bibliography

Seguridad Social en Salud Colombiano BogotaacuteColombia 2010

8 Pinzoacuten C Torres M Duarte A Gaitaacuten H GrupoCochrane de Infecciones de Transmisioacuten SexualAlianza CINETS Revisioacuten sistemaacutetica MixtaModelos de Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica Bogotaacute 2013

9 Rycroft-Malone J The PARIHS Framework ndash AFramework for Guiding the Implementation of Evidence-based Practice J Nurs Care Qual 200419(4)297-304

10Legido-QuigleyHMckeeMClinicalGuidelinesforChronic Conditions in the European Union Policies EO on HS and editor United Kingdom WorldHealth Organization 2013

11 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico InstitutoAragoneacutesdeCienciasde laSaludeditorMadrid 2009

12 Rogers EMDiffusion of innovations Fifth ed New YorkFreePress2003

13DaviesDATaylor-VasiseyAtranslatingguidelinesinto practice a systematic review of theoreticconcepts practical experience and researchevidence in the adoption of clinical practice guidelinesCMAJ1997157408-416

14RabinBAandBrownsonRC(2012)Developingthe terminology for dissemination and implementation research in health In Brownson RC ColditzGA amp Proctor EK (Eds) Dissemination andImplementation Research in Health Translating


Science to Practice New York Oxford UniversityPress (httpwwwmakeresearchmatterorgglossaryaspx38)

15 Glisson C James LR The cross-level effects ofculture and climate in human service teams J OrganBehav200223767-794

16GilsonLSchneiderHManagingscalingupwhatare the key issues Health Policy and Planning20102597-98

17 ProctorESilmereHRaghavanRetalOutcomes for ImplementationResearchConceptualDistinctionsMeasurement Challenges andResearchAgendaAdmPolicyMentHealth20113865-76

18 Lomas J Diffusion dissemination andimplementationwhoshoulddowhatAnnNYAcadSciDec311993703226-235discussion235-227

19 National Institutes of Health PA-08-166Dissemination Implementation and OperationalResearch for HIV Prevention Interventions (R01) 2009

20ShiffmanRNDixonJBrandtCEssaihiAHisiaoAMichelGOrsquoConellRTheGideLineImplementabilityAppraisal(GLIA)developmentofan instrumenttoidentify obstacles to guideline implementation BMC MedInformDecisMaK2005523

21Legido-QuigleyHPanteliDBrusamentoSKnaiCSalibaVTurkESoleacuteMAugustinUCarJMcKeeM Busse R Clinical guidelines in the EuropeanUnionMappingtheregulatorybasisdevelopmentquality control implementation and evaluationacross member states Healthpolicy (AmsterdamNetherlands)2012107(2)146-156

22 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social ResolucioacutenNdeg0001442de2013por la cual se adoptan las Guiacuteas de Praacutectica Cliacutenica ndashGPCparaelmanejodelasLeucemiasyLinfomasennintildeosnintildeasyadolescentesCaacutencerdeMama

CaacutencerdeColonyRectoCaacutencerdeProacutestataysedictan otras disposiciones

23 Repuacuteblica de Colombia Ministerio de Salud yProteccioacuten Social Resolucioacuten Ndeg 0001441 de 2013 por la cual sedefinen losprocedimientos ycondicionesquedebencumplirlosPrestadoresdeServicios de Salud para habilitar los servicios y se dictan otras disposiciones

24 Grupo de trabajo sobre implementacioacuten de GPC Implementacioacuten de Guiacuteas de Praacutectica Cliacutenica en el Sistema Nacional de Salud Manual Metodoloacutegico Plan de Calidad para el sistema Nacional de Salud del Ministerio de Sanidad y Poliacutetica Social Instituto Aragoneacutes de Ciencias de la Salud-I+CS 2009 Guiacuteas de Praacutectica Cliacutenica en el SNS I+CS Nordm200702-02

25 Grupo de variaciones en la praacutectica meacutedica de la red temaacutetica de investigacioacuten en Resultados y servicios de salud (Grupo VPC-IRYS) Variaciones en cirugiacutea ortopeacutedica y traumatoloacutegica en el Sistema Nacional de Salud Atlas de variaciones en la praacutectica meacutedica GestioacutenCliacutenicaySanitaria2005117-36

26 Fisher MA Avorn J Economic implications ofevidence-based prescribing for hypertension canbetter care cost less JAMA 2004291(15)1850-1856

27 Grupo de meacutetodos para el desarrollo de Guiacuteas de Praacutectica Cliacutenica Guiacutea para el desarrollo de Guiacuteas dePraacutecticaCliacutenicabasadasenlaevidenciaManualMetodoloacutegico Grupo de evaluacioacuten de tecnologiacuteas ypoliacuteticasensalud(GETS)UniversidadNacionaldeColombia2009ISBN978-958-44-6228-2

28Ruelas E 1994 Sobre la calidad de la atentionmeacutedicaConceptosaccionesyreflexionesGacetaMeacutedicadeMeacutexico130218-30

29ProgramadeApoyoalaReformadeSaludndashPARSMinisteriode laProteccioacutenSocialndashMPSCalidaden salud en Colombia Los principios Proyecto

Bibliography



EvaluacioacutenyajustedelosProcesosEstrategiasyorganismos encargados de la operacioacuten del Sistema de garantiacutea de calidad para las instituciones de prestacioacuten de servicios (1999 2001) Marzo 2008

30 Duarte A Construccioacuten de un Manual para el desarrollo de los planes de implementacioacuten de lasGuiacuteasdePraacutecticaCliacutenicandashGPCcontenidasenlas Guiacuteas de Atencioacuten Integral -GAIen el Sistema General de Seguridad Social en Salud de Colombia -SGSSS- Tesis de Maestriacutea de Epidemiologiacutea CliacutenicaPontificiaUniversidadJaveriana2012Sinpublicar

31 Grimshaw JM Thomas RE MacLennan GFraserGRamsayCRValeLetalEffectivenessand efficiency of guideline dissemination andimplementation strategies Health Technol Assess 20048(6)1-84



gpcminsaludgovco

1 Introduction

2 Glossary

3 The implementation process in the Colombian Social Security System in Health


32 Scope and population under the CPG national implementation process


331Ministry of Health and Social Protection (MSPS)

332Institute for Health Technology Assessment (IETS)

333Guideline Developer Groups (GDG)

334Health Insurers (EPS or APB)

335Health Service Provider Institutions

336Higher Education Institutions

337Scientific Societies

338Associations of users and patients

339Patients

4 Phase 1 planning and construction of the implementation plan


411Steps for the adoption of CPG

42 Establishment of the institutional implementation team and definition of roles

43 Creation of institutional implementation plan

431 Selection of the Guideline to implement

432 Identification of barriers and facilitators

433 Definition of strategies and dissemination activities

434 Selection of implementation tools

435 Definition of the incentive plan

436 Identification of resources needed for implementation

437 Preparation of the schedule of activities

438 Selection of evaluation and control mechanisms


45 Practical steps in defining the institutional implementation plan




61 Monitoring


621 Components of the evaluation



Annexes

Annex 1Comprehensive implementation model ofclinical practice guidelines




Bibliografiacutea

Implementation guide 1pdf

Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning

and construction of the implementation plan











copy Ministerio de Salud y Proteccioacuten Social

Departamento Administrativo de Ciencia Tecnologiacutea e Innovacioacuten ndash Colciencias

Implementation manual for evidence-based clinical practice guidelines in health services provider institutions in Colombia

ISBN 978-958-8903-08-8Bogotaacute Colombia2014

This document has been prepared under contract 478 2013 of Ministerio de Salud y Proteccioacuten Social and the Universidad de Antioquia


































CPG Pregnancy




















































Content

1 INTRODUCTION 11

2 GLOSSARY 15


SYSTEM IN HEALTH 19












339 Patients 23




















61 Monitoring 42





ANNEXES 47

BIBLIOGRAPHY 67

1 Introduction


Introduction















2 Glossary


Glossary
































System in Health










































CPG implementations





















implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


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Case study



















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Theeventhas4phases





























































Bibliography



























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gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning













































CPG Pregnancy




















































Content

1 INTRODUCTION 11

2 GLOSSARY 15


SYSTEM IN HEALTH 19












339 Patients 23




















61 Monitoring 42





ANNEXES 47

BIBLIOGRAPHY 67

1 Introduction


Introduction















2 Glossary


Glossary
































System in Health










































CPG implementations





















implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning





































Content

1 INTRODUCTION 11

2 GLOSSARY 15


SYSTEM IN HEALTH 19












339 Patients 23




















61 Monitoring 42





ANNEXES 47

BIBLIOGRAPHY 67

1 Introduction


Introduction















2 Glossary


Glossary
































System in Health










































CPG implementations





















implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning




















61 Monitoring 42





ANNEXES 47

BIBLIOGRAPHY 67

1 Introduction


Introduction















2 Glossary


Glossary
































System in Health










































CPG implementations





















implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning












1 Introduction


Introduction















2 Glossary


Glossary
































System in Health










































CPG implementations





















implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning













Introduction















2 Glossary


Glossary
































System in Health










































CPG implementations





















implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning




















2 Glossary


Glossary
































System in Health










































CPG implementations





















implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning













Glossary
































System in Health










































CPG implementations





















implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning

























System in Health










































CPG implementations





















implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning





















































CPG implementations





















implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning

























implementation plan










































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning





















































Innovation






Patient



Social Context









































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning







































Strategy Definition



























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning

























Process







Financing










Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning














Associated factors


Human re-sources







Information Systems






































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning




































































changeandefficiency








61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning



















61 Monitoring



























videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning































videoconferences

Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning












Annexes





Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning
















Date

Institution










1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning















1

2

3

4

5

6

7

8


Recommendation


Recommendation


Recommendation











the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning





















the information











Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning






















Concerning the CPG






Con

cern

ing

prof

essi

onal

s



YES NO











Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning














Con

cern

ing

the

econ

omic

and

org

aniz

atio

nal c

onte

xt




YES NO


YES NO








Other Bar-riers

YES NO

YES NO


















Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning





























Pre-consideration









Consideration











Preparation













Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning















Action









Maintenance













minus Use mnemonics




minus Paraphrase

minus Teach others







































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning















































Confe-renceLecture


minus Room


minus Sound









Case study



















Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning













Case study


























































Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning






























Theeventhas4phases





























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning
























































Bibliography



























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning






























Bibliography








gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning



















gpcminsaludgovco

1 Introduction

2 Glossary













339Patients



















61 Monitoring





Annexes





Bibliografiacutea


Bibliografiacutea

_GoBack

1 Introduction

2 Glossary













339Patients

4 Phase 1 planning












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