• We are sorry, but NCBI web applications do not support your browser and may not function properly. More information
Logo of qualhcLink to Publisher's site
Qual Health Care. Sep 1999; 8(3): 177–183.
PMCID: PMC2483658

A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines

Abstract

Theories from social and behavioural science can make an important contribution to the process of developing a conceptual framework for improving use of clinical practice guidelines and clinician performance. A conceptual framework for guideline dissemination and implementation is presented which draws on relevant concepts from diffusion of innovation theory, the transtheoretical model of behaviour change, health education theory, social influence theory, and social ecology, as well as evidence from systematic literature reviews on the effectiveness of various behaviour change strategies. The framework emphasises the need for pre-implementation assessment of (a) readiness of clinicians to adopt guidelines into practice, (b) barriers to change as experienced by clinicians, and (c) the level at which interventions should be targeted. It also incorporates the need for multifaceted interventions, identifies the type of barriers which will be addressed by each strategy, and develops the concept of progression through stages of guideline adoption by clinicians, with the use of appropriately targeted support strategies. The potential value of the model is that it may enable those involved in the process of guideline dissemination and implementation to direct strategies to target groups more effectively. Clearly, the effectiveness and utility of the model in facilitating guideline dissemination and implementation requires validation by further empirical research. Until such research is available, it provides a theoretical framework that may assist in the selection of appropriate guideline dissemination and implementation strategies.

Full Text

The Full Text of this article is available as a PDF (90K).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993 Nov 27;342(8883):1317–1322. [PubMed]
  • Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995 Nov 15;153(10):1423–1431. [PMC free article] [PubMed]
  • Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA. 1992 Sep 2;268(9):1111–1117. [PubMed]
  • Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995 Sep 6;274(9):700–705. [PubMed]
  • Grol R. Personal paper. Beliefs and evidence in changing clinical practice. BMJ. 1997 Aug 16;315(7105):418–421. [PMC free article] [PubMed]
  • Robertson N, Baker R, Hearnshaw H. Changing the clinical behavior of doctors: a psychological framework. Qual Health Care. 1996 Mar;5(1):51–54. [PMC free article] [PubMed]
  • Prochaska JO, Velicer WF, Rossi JS, Goldstein MG, Marcus BH, Rakowski W, Fiore C, Harlow LL, Redding CA, Rosenbloom D, et al. Stages of change and decisional balance for 12 problem behaviors. Health Psychol. 1994 Jan;13(1):39–46. [PubMed]
  • Firth-Cozens J. Healthy promotion: changing behaviour towards evidence-based health care. Qual Health Care. 1997 Dec;6(4):205–211. [PMC free article] [PubMed]
  • Stocking B. Why research findings are not used by commissions--and what can be done about it. J Public Health Med. 1995 Dec;17(4):380–382. [PubMed]
  • Stocking B. Implementing the findings of Effective Care in Pregnancy and Childbirth in the United Kingdom. Milbank Q. 1993;71(3):497–521. [PubMed]
  • Conroy M, Shannon W. Clinical guidelines: their implementation in general practice. Br J Gen Pract. 1995 Jul;45(396):371–375. [PMC free article] [PubMed]
  • Felch WC. Bridging the gap between research and practice. The role of continuing medical education. JAMA. 1997 Jan 8;277(2):155–156. [PubMed]
  • Hayward RS, Wilson MC, Tunis SR, Guyatt GH, Moore KA, Bass EB. Practice guidelines. What are internists looking for? J Gen Intern Med. 1996 Mar;11(3):176–178. [PubMed]
  • Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983 Jun;51(3):390–395. [PubMed]
  • Cohen SJ, Halvorson HW, Gosselink CA. Changing physician behavior to improve disease prevention. Prev Med. 1994 May;23(3):284–291. [PubMed]
  • Wensing M, Grol R. Single and combined strategies for implementing changes in primary care: a literature review. Int J Qual Health Care. 1994 Jun;6(2):115–132. [PubMed]
  • Gupta L, Ward J, Hayward RS. Future directions for clinical practice guidelines: needs, lead agencies and potential dissemination strategies identified by Australian general practitioners. Aust N Z J Public Health. 1997 Aug;21(5):495–499. [PubMed]
  • Marshall MN. Qualitative study of educational interaction between general practitioners and specialists. BMJ. 1998 Feb 7;316(7129):442–445. [PMC free article] [PubMed]
  • McColl A, Smith H, White P, Field J. General practitioner's perceptions of the route to evidence based medicine: a questionnaire survey. BMJ. 1998 Jan 31;316(7128):361–365. [PMC free article] [PubMed]
  • Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992 Nov 4;268(17):2420–2425. [PubMed]
  • Mittman BS, Tonesk X, Jacobson PD. Implementing clinical practice guidelines: social influence strategies and practitioner behavior change. QRB Qual Rev Bull. 1992 Dec;18(12):413–422. [PubMed]
  • Day F, Hoang LP, Ouk S, Nagda S, Schriger DL. The impact of a guideline-driven computer charting system on the emergency care of patients with acute low back pain. Proc Annu Symp Comput Appl Med Care. 1995:576–580. [PMC free article] [PubMed]
  • Stokols D. Establishing and maintaining healthy environments. Toward a social ecology of health promotion. Am Psychol. 1992 Jan;47(1):6–22. [PubMed]
  • Elson RB, Connelly DP. Computerized patient records in primary care. Their role in mediating guideline-driven physician behavior change. Arch Fam Med. 1995 Aug;4(8):698–705. [PubMed]
  • Johnston ME, Langton KB, Haynes RB, Mathieu A. Effects of computer-based clinical decision support systems on clinician performance and patient outcome. A critical appraisal of research. Ann Intern Med. 1994 Jan 15;120(2):135–142. [PubMed]
  • Petrie JC, Grimshaw JM, Bryson A. The Scottish Intercollegiate Guidelines Network Initiative: getting validated guidelines into local practice. Health Bull (Edinb) 1995 Nov;53(6):345–348. [PubMed]
  • Lomas J, Haynes RB. A taxonomy and critical review of tested strategies for the application of clinical practice recommendations: from "official" to "individual" clinical policy. Am J Prev Med. 1988;4(4 Suppl):77–97. [PubMed]

Articles from Quality in Health Care : QHC are provided here courtesy of BMJ Group

Formats:

Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...

Links

  • PubMed
    PubMed
    PubMed citations for these articles