Implementation Guide and Toolkit for National Clinical

Implementation Guide and Toolkitfor National Clinical Guidelines

National Patient Safety OfficeOifig Náisiúnta um Shábháilteacht Othar

Feasibility

Capacity

OutcomesImpact

ReachFitLeadership

AdherenceFidelityEnablers

Adoption

Cost

Implementation planning

Organisational culture

Intervention readiness

Stakeholder engagement

Implementation Science

Knowledge translation

Situation analysis

Capacity building

Behaviour change

Needs assessment

Appropriateness

Evidence-based

Effectiveness

Acceptability

Communication

Dissemination

Maintenance

Logic model

Competency

Sustainability

The National Clinical Effectiveness Committee (NCEC) is a Ministerial committee of stakeholders, including patient representatives, that was established to oversee a National Framework for Clinical Effectiveness. Its Terms of Reference are:

1. Provide strategic leadership for the national clinical effectiveness agenda.

2. Contribute to national patient safety and quality improvement agendas.

3. Publish standards for clinical practice guidance.

4. Publish guidance for National Clinical Guidelines and National Clinical Audit.

5. Prioritise and quality assure National Clinical Guidelines and National Clinical Audit.

6. Commission National Clinical Guidelines and National Clinical Audit.

7. Align National Clinical Guidelines and National Clinical Audit with implementation levers.

8. Report periodically on the implementation and impact of National Clinical Guidelines andthe performance of National Clinical Audit.

9. Establish sub-committees for NCEC workstreams.

10. Publish an Annual Report.

Published by:The Department of HealthBlock 1, Miesian Plaza, 50-58 Lower Baggot St, Dublin 2, D02 XW14, Ireland Tel: +353 (1) 6354000https://health.gov.ie/ [email protected]

September 2018. © Department of Health, September 2018.

Citation text: Department of Health (2018). NCEC Implementation Guide and Toolkit. Available at: https://health.gov.ie/national-patient-safety-office/ncec/In text citation: (Department of Health 2018)

https://health.gov.ie/

https://health.gov.ie/national-patient-safety-office/ncec/

Contents

Development of the Guide ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 2

How to use this Guide .. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 3

Implementation of Clinical Guidelines . ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 5

Introduction to Implementation Science... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 8 WhatisImplementationScience? 8 ImplementationFrameworks 9 ImplementationStages 10 AssessingImplementationStage 12 EnablersandBarriers 12 ContextforImplementation 13 StrategiesforImplementation 14

Stage 1: Exploring and Preparing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 16

Stage 2: Planning and Resourcing ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 28

Stage 3: Implementing and Operationalising . ... ... ... ... ... ... ... ... ... ... ... ... ... .. 46

Stage 4: Full Implementation . ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 52

Glossary ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 56

References ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 60

Additional Implementation Websites and Resources... ... ... ... ... ... ... ... ... ... ... .. 66

Appendix A ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 68

Tool 1 – The Hexagon Tool. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 72

Tool 2 – Logic Model ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 73

Tool 3 – Implementation Enablers and Barriers: Assessment Tool... ... ... ... ... ... ... .. 75

Tool 4 – Implementation Planning Tool ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 89

Tool 5 – Monitoring and Evaluating Implementation: Planning Tool ... ... ... ... ... ... .. 92

2 Implementation Guide and Toolkit for National Clinical Guidelines

Development of the GuideThe development of this Implementation Guide was informed by Implementation ScienceliteratureandresourcesandconsultationandinteractionswiththeClinicalEffectivenessUnitintheDepartmentofHealthandmembersofGuidelineDevelopmentGroups.

FundingTheprocessfordevelopingthisguidefortheNCECwasfundedbytheDepartmentofHealthandoverseen by the Clinical Effectiveness Unit of the National Patient Safety Office, Department ofHealth.

AuthorsTheguidewasproducedbytheCentreforEffectiveServices(CES). www.effectiveservices.org TheauthorsareDrAislingSheehan,MrChrisMinchandMsKatieBurke.

AcknowledgementsThe Clinical EffectivenessUnitwould like to thank the following peoplewho contributed to thedevelopmentoftheGuideinvariousways,includingtheprovisionofworkedexamplesoftoolsandprovidingfeedbackonearlierdraftsofthisGuide:

• MsMaryBeddingandMsChristinaDoyle,SepsisGuidelineDevelopmentGroup,HSE• MsBrídBoyce,NationalQualityImprovementDivision,HSE• MsCatherineDuffyandDrEveO’TooleonbehalfoftheNationalCancerControlProgramme

(NCCP),HSE• Dr Helena Gibbons,Ms LouiseMurphy and Dr Niamh Kilgallen, Ovarian Cancer Guideline

DevelopmentGroup,NCCP,HSE• DrPatrickGlackin,AreaDirectorofNursingandMidwiferyPlanningandDevelopment,HSE

West• MsCaralynHorne,PortfolioLead-ProgrammeManagementOffice,MidlandsLouthMeath

CHOArea8,HSE• MsMaryCMorrissey,ResearchandDevelopment,StrategicPlanningandTransformation,HSE• MsClareO’Neill,Risk&IncidentMonitoring,SupportandLearningOfficer,Quality&Service

UserSafety,HSENationalCommunityOperations• DrKarenPower,ChildbirthGuidelineDevelopmentGroup.

PermissionsPermission has been granted by the National Implementation Research Network (NIRN) foradaptationoftheirHexagonToolinthisGuide.PermissionhasalsobeenobtainedtoincludeProctoretal.’s(2010)TaxonomyofOutcomes[28] andimagesfromtheIHIFrameworkforLeadershipforImprovementandtheBehaviourChangeWheel.

http://www.effectiveservices.org

3Implementation Guide and Toolkit for National Clinical Guidelines

How to use this Guide

Who is this guide for?The purpose of this Implementation Guideis primarily to support those involved in thedevelopment and implementation of NationalClinical Guidelines, for planning implementationactivities. Throughout this guide we refer to‘guidelines’astheinterventionforimplementation.However, it will also be of interest to thoseinvolved in the development and implementationof other evidence-based interventions, such asclinical practice guidance; policies, procedures,protocols and guidelines (PPPGs), and auditrecommendations.

ThroughoutthisGuide,werefer to ‘GuidelineGroups’.This refers toboththe initialGuidelineDevelopment Group and the post-publication implementation team(s). There will be someoverlap between the initial Guideline Development Group and the implementation team(s).The implementation team isgenerallyanational team,butadditional local teamscanalsobeestablished as required. The implementation team(s) take the guideline forward through theimplementationstages,inpartnershipwiththewiderhealthserviceorganisation.

When will it be used?ThisImplementationGuideprovidesthetheory,stepsandtoolsforeachstageofimplementation.WhilstitisrecommendedthattheImplementationGuidebeusedfromtheoutsetinguidelinedevelopment, existing Guideline Development Groups will also find the various tools useful,regardlessofwhatstageofdevelopmenttheyareat.

What needs to be included in the guideline?NCECGuidelinesalreadyincludeaplanforimplementation.NewGuidelineDevelopmentGroupswill beexpected to include the following implementation components in their submission forQualityAssuranceandinthefinalpublishedguideline:

• Logicmodel(onepage)• Implementationplan(actions,timeframe,personsresponsible,expectedoutcomes)

Templatesandworkedexamplesfortheseareincludedinthisguide.


ThisImplementationGuideprovidesreaderswith:üContextforthe importanceof ImplementationScience insuccessfully implementingclinical

guidelinesüAnoutlineofImplementationSciencetheoryandanintroductiontokeyconceptsüKeyelementscommontoimplementationframeworksüApackageofinformation,toolsandresourcestofacilitatediscussions,thinking,andplanning

for implementation at various stages of the guideline development and implementationprocess.

ThisGuidebuildsoninformationdeliveredbytheCentreforEffectiveServicesfortheNationalClinicalEffectivenessCommittee (NCEC) in the Department of Health ata two-day Introductory Training in ImplementationScience and a series of three additional workshops onspecific implementation topics delivered to healthcarepractitioners, healthcare staff and other stakeholders.However,itisdesignedinsuchawaythatitcanbereadandusedbystakeholderswhowerenotattheseeventsorwhohaveabroaderscope.

The first section of this Guide is intended as a source of evidence for why implementation ofclinicalguidelinesisanimportantandusefultopic.Followingthat,thereisabriefoverviewofthemain theories and concepts put forward in Implementation Science. This will serve as a usefulintroductionforthosewhoarenewtoImplementationScience,orasarefresherforthosewhoarefamiliarwith thedisciplineand/orwhohaveattended relevant training sessionsandworkshops.ReferencesareprovidedwithhyperlinksattheendofthisGuide,whereavailable,andthereisalsoalistoffurtherresources,forthosewhowouldliketoreadfurther.

The remaining sections provide information, tools and resources for the most relevant andimportantimplementationconsiderationsthroughoutguidelinedevelopmentandimplementation.Implementation stages are discussed in somedetail in thisGuide, and it is especially helpful toidentify which stage a guideline/project is at in the implementation process. ImplementationplanningisalsodiscussedindetailinthisGuideandatemplateforcreatinganimplementationplanisincludedinTool4.

However, it is important to note that “implementing research evidence is not just a matter of following procedural steps” [2,p.4].Accordingly,thisGuideisnotastep-by-stepguideorchecklistfor implementing clinical guidelines. Rather, it provides a package of information, tools andresourcestohelpguidediscussions,thinkingandplanningaroundimplementation.ItwillbeuptoGuidelineDevelopmentGroups,implementationteamsandotherrelevantstakeholderstoidentifyimplementation activities, given the context in which they are implementing and the nature ofwhatisbeingimplemented.Naturally,thesewillvaryonacase-by-casebasis,andwebelievethatthisGuidewillbecomeincreasinglyusefulaspeoplegainexperienceandknowledgeofboththetheoryofImplementationScienceandthepracticeofimplementingintherealworld.

Clinical Guidelinesare‘systematicallydevelopedstatements,basedonathoroughevaluationoftheevidence,toassistpractitionerandserviceusers’decisionsaboutappropriatehealthcareforspecificclinicalcircumstancesacrosstheentireclinicalsystem’[1]


Implementation of Clinical GuidelinesIn Ireland, clinical guidelines that meet specific prioritisation and quality-assurance criteria setforthbytheNCECareendorsedbytheMinister forHealthandaretitled ‘NCEC National Clinical Guidelines’. This is in line with evidence indicating that the quality assurance and evaluationprocessesusedindevelopingclinicalguidelinesinternationallyhasimprovedsincethe1990s[3]

However, there is little international evidence ofconsistent improvements in the dissemination,implementationandclinicaluseofclinicalguidelines.Forexample, studieshaveshown thatup to50%ofpatients can fail to receive clinical interventions inaccordancewiththebestclinicalevidenceandlatestclinicalguidelines[4,5]

Guidelines have often been found to contain alargevolumeofclinical information,andhavebeendescribedvariouslyas ‘cumbersome’ [6]and‘unmanageable’ [7]. Thishas left thoseusing theguidelines “frustrated with the vast number of guidelines and uncertain about how to implement them” [8,p.1].Evenwhencliniciansareawareof and in agreementwith clinical guidelines, adoptionandadherence canbe low, and cliniciansindicateadesireformoreguidanceandsupporttoimplementthem[9]

Not only is this a sub-optimal return on considerable investment of public money [10], it alsoindicatesasignificantlossinpotentialhealthgainsforpatientsandpopulations[5].InIreland,thisisadrivingfactorbehindtheproductionofthisGuideandtheincreasingfocusonimplementationofclinicalguidelines.

Thereisanopportunityforguidelinedevelopersandstakeholderstodomoretotranslateclinicalguidelinesintousablematerialsforpractitionerswithlittletimeandresources.“Merely circulating guidelines or other documents to health professionals has only a small effect on practice” [3,p 276]–healthprofessionalsalsorequiredisseminationand implementationactivities,toolsandresources thatwillhelp tomaximiseusageofguidelines [10].Guidelinesshouldbepresented inamanner that is clear, precise and usable, for example in summary documents, ‘Plain English’versions,orpoint-ofcarechecklistsandforms[11]

Theimportanceofdedicatingtimeandresourcestoimplementationofclinicalguidelinesisbeingincreasinglyrecognised,andtheNCEChasincludedconsiderationofimplementationissuesaspartofprioritisationandqualityassuranceprocessesforNationalClinicalGuidelines.

Prioritisation occurs at the beginning of the guideline development process. Key aspects ofimplementationwhichareassessedbytheNCECduringtheguidelineprioritisationstage include[12,p.12]:

• Whatisthefeasibilityofimplementationoftheclinicalguideline?• Whatarethefacilitatorstotheguidelineapplication?• Arethereanysignificantbarrierstoimplementationoftheclinicalguideline?• Whatistheresourceimpactforimplementationoftheclinicalguideline?• How acceptable will the clinical guideline be to relevant stakeholders (consumers and

clinicians)?

Implementationinvolvesthecarryingoutofspecificplanned,intentionalactivitiesundertakenwiththeaimofmakingevidence-informedpoliciesandpracticesworkbetterforpeople.Itcanbethoughtofasthe‘how’aswellasthe‘what’.


• DidtheGuidelineDevelopmentGroupincludeindividualsfromalltherelevantprofessionalgroups,methodological experts and intended users, for example healthcare professionals,hospitalmanagersetc.?

• Isthereadegreeofurgencyforimplementationoftheclinicalguideline?• Whatisthelikelihoodoftheclinicalguidelineimplementationstrategybeingsuccessful?• Howaccessiblewilltheclinicalguidelinebe?

KeyaspectsofimplementationwhichareassessedduringtheNCECqualityassuranceprocessformpartofthe‘Applicability’domainoftheAppraisalofGuidelinesforResearchandEvaluation(AGREEII)tool[13],namely:

• Theguidelinedescribesfacilitatorsandbarrierstoitsapplication• The guideline provides advice and/or tools on how the recommendations can be put into

practice• Thepotentialresourceimplicationsofapplyingtherecommendationshavebeenconsidered• Theguidelinepresentsmonitoringand/orauditingcriteria.

ThisguideandthetoolsareavailableontheDepartment of Health NCEC website:http://health.gov.ie/national-patient-safety-office/ncec/

Other resources relating to National Clinical Guidelines, National Clinical Audit and ClinicalPracticeGuidancearealsoavailableonthe Department of Health NCEC website linkedabove.Thisincludesresourcesonguidelineprioritisationandqualityassuranceprocesses,suchasthe:

• Preliminary Prioritisation Process for National Clinical Guidelines• National Quality Assurance Criteria for Clinical Guidelines• Guideline Developers Manual

Trainingmaterials, including videos and e-learning are available on theDepartment ofHealth National Patient Safety Office Learning Zone: https://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/

http://health.gov.ie/national-patient-safety-office/ncec/

https://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/


Introduction to Implementation Science


Introduction to Implementation Science

What is Implementation Science?Implementationfocusesonoperationalisingaplan–itisabout‘How’somethingwillbecarriedout,aswellas‘What’willbecarriedout[14].Itisbothanartandascience,harnessingknowledgefromacademicresearchandpracticewisdom,withtheaimofsuccessfully incorporating interventionsinto typical service settings, in order to improve outcomes for service users (children, adults,families,communitiesandsociety)[15]

Diffusionlettingithappen

Disseminationhelpingithappen

Implementationmakingithappen

Implementation is conceptually distinctfrom diffusion and dissemination. Diffusionis a passive process, described as ‘letting ithappen’, meaning the intervention follows anunpredictable, unprogrammed, emergent andself-organising path. Dissemination is a moreactive, negotiated and influenced means ofdelivering an intervention (‘helping it happen’).Implementation is the most active form ofdelivering interventions – it involves ‘making ithappen’,throughscientific,orderly,plannedandmanagedactivities[16]

Implementation Scienceistheformalstudyofmethodsandfactorsthatinfluencehowsuccessfullyspecificinterventionsareincorporatedintoservicesettings,leadingtoimprovedoutcomes.

Implementation Science is linked to and builds on a number of related disciplines includingImprovement Science, Quality Improvement, Project Management, Change Management,KnowledgeTranslationandOrganisationalDevelopment.

ItisworthnotingwhatImplementationScienceisnot:ûA magic formula – ImplementationScienceisnottheanswertoallImplementationproblems

andwillnotguaranteethesuccessofclinicalguidelines.Thereareamyriadoffactorsaffectingimplementationsuccess,andsometimesitmaynotbepossibleorfeasibletoaddressthemall.

ûA mystical and inaccessible language – while some Implementation Science literature cancontainjargon,itbuildson‘commonsense’andknowledgefromarangeofrelateddisciplines.

ûA way of proving an evidence-based intervention – Implementation Sciencewill not provewhetheraninterventioniseffectiveornotandusingImplementationSciencewillnotturnabadinterventionintoagoodone.

Interventionsareanyevidence-informedpolicy,practice,serviceorprogrammebeingimplemented,beitachangetoanexistingpolicy,practice,serviceorprogramme,oranewintervention.

InthisGuide,weuseinterventiontorefertospecificrecommendationscontainedwithinNationalClinicalGuidelines,ClinicalPracticeGuidance(PPPGs)andNationalClinicalAudit.


Asafieldofstudy,ImplementationSciencehasgrowninpopularityoverthelastdecade,andthereisnowaconsiderablebodyofresearchfromawiderangeofsectorsindicatingsomeofthemostimportantfactorsindeterminingwhetherimplementationwillbesuccessfulornot.Implementationisanotachallengeuniquetothehealthsector.Rather,itisauniversalphenomenon,andlessonsinImplementationSciencehavebeenobtainedfromfieldsasdisparateaseducationandtraining;manufacturing and engineering; agriculture and forestry; business and information technology;andmore.

Effective Interventions

The “WHAT”

Effective Implementation

Methods The “HOW”

Socially Significant Outcomes

Enabling Contexts

Enabling Contexts

Having an effective intervention is just one part (albeit an important one) of getting to positiveoutcomes.ImplementationSciencehelpsustoidentifytheeffectiveimplementationmethodsandenabling contexts that form the remaining parts of the equation and improve the likelihood ofreachingtheintendedoutcomes[15]

Implementation FrameworksImplementation frameworks provide a conceptual modelofimplementation,servingtodescribespecificstepsintheplanningandexecutionofimplementation,andhighlightingpotentialpitfalls.

The past decade has seen an increase in the number offrameworksappearinginImplementationScienceresearch.In2012,thecountwasatmorethan60frameworks[17];in2017, itwas100ormore[18].Theseframeworksdiffer intermsofassumptions,aims,context(policy,practice,etc.),andsectors(publichealth,childwelfare,etc.).

• Websites such as the ‘Dissemination & Implementation Models in Health Research & Practice’arenowbeingcreatedtohelpresearchers,policymakersandpractitionersdeterminewhich framework, or elements of a particular framework,will bemost relevant for theirimplementationproblem.

To access this website, click here:http://www.dissemination-implementation.org/

• Forthoseinterestedinreadingfurther,theCentre for Effective Services has created a short document summarising several implementation frameworks withlinksforfurtherreading.

To access the Summary of Implementation Science Frameworks, click here or see Appendix A.

Thetermstheory, modelandframeworkareoftenusedinterchangeably.

Foradetaileddescriptionoftheseterms,withparticularrelevancetoImplementationScience,seeNilsen,2015 [19]

http://www.dissemination-implementation.org/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4406164/


While Implementation Science is producing growing evidence of generalisable lessons formoreeffective implementation, the evidence for any individual implementation framework is limited.There is also significantoverlapamongmanyof the frameworks.Asa result, there is a growingemphasis on combining and improving existing frameworks, and on using the most relevantelementsofanyoneormoreframeworksgivenaspecificcontext.

TheremainderofthissectionwillfocusonsomeofthecoreelementsofImplementationScience.Thesecoreelementsare:

Implementation Stages

Enablers and Barriers

Context for Implementation

Implementation Strategies

Implementation StagesImplementation frameworks almost unanimously conceptualise the implementation of anyinterventionaspassingthroughagivennumberofstages.Thenumberofstagesvariesbetweenframeworks(usually3-5),asdoesthenamesprovidedforeachofthestages.

Key messages from Implementation Stages:• Youcannot skip any stageof implementation.Eachstagerequiresstakeholders’timeand

attention.• Implementation takes time;estimatesvaryfrom2-4yearsto7-10years,dependingonscale

andcomplexity.Rushingthroughstagesorworkingaparticularlylargenumberofhoursinashorttimedoesnotadequatelycompensateforthisneed.

• Thestagesarenot linear.Manyoftheactivitiesoverlap,andyoumayneedtore-visitorbringforwardtasksfromotherstages asnecessary.

• Therearearange of toolsavailabletohelpGuidelineGroupsnavigateeachstage.ThesearesignpostedthroughouttheremainderofthisGuide.


The four-stage model below is one way to visualise the implementation process of clinical guidelines:

Stage 2: Planning & Resourcing

Herethefoundationislaidforeffectiveimplementation.

Key activities at this stageinclude:• Assessingimplementation

readiness• Assessingenablersand

barriersforimplementation• Developingan

implementationplan• Establishingimplementation

team(s)andinfrastructureforimplementation

• Developingleadershipforimplementation

• Designingmonitoring,evaluationandfeedbacksystems

• Determininganddeliveringstafftraining,capacitybuildingandsupportrequirements

• Planningforguidelinesustainability

Stage 4: Full Implementation

Theguidelineisfullyoperationalandintegrated,usedconsistently,andsupportedbystructuresandresources.

Key activities at this stageinclude:• Evaluatingimplementation

outcomes,serviceoutcomesandclientoutcomes

• Engagingincontinuousimprovementcyclestoenhancequality

Stage 1: Exploring & Preparing

Here the needs of stakeholders are assessed, the reason/rationale for developing theguidelineisclarified,andthescopeoftheguidelineisdetermined.

Key activities atthisstageinclude:• Stakeholderengagementplanning• Assessingneedsandtheevidencebaseforaguideline• Definingkeyclinicalquestionstobeaddressed• Assessingthefit,feasibilityandimplementabilityofpotentialrecommendations• Specifyingoutcomeswhichtheguidelineseekstoachieve• DevelopingaTheoryofChangeandLogicModel

Stage 3: Implementing & Operationalising

Heretheguidelineisimplementedforthefirsttime.

Keyactivitiesatthisstageinclude:• Maintainingongoingcommunication,explainingwhytheguidelineisnecessaryand

securingcontinuedbuy-in• Providingongoingprofessionaldevelopmentopportunitiesandsupportforstaff

implementingguidelines• Ongoingmonitoringofimplementationoutcomes,serviceoutcomesandclientoutcomes• Usingdataandfeedbackmechanismstoinformongoingimprovements• Adaptingimplementationplansforlocalsettings,whereappropriate

1. Exploring & Preparing

4. Full Implementation

2. Planning & Resourcing

3. Implementing & Operationalising


Assessing Implementation StageIt is very useful for Guideline Groups to assess what stage of implementation their guidelineis at. This allows groups to get a sense of how far along the implementation process they are,and consider the most appropriate activities for them, given their stage. Strictly speaking, thisassessment could occur at any stage of guideline development and implementation, but isparticularlyusefulinstages1and2,forthepurposesofplanningandresourcing.

The Implementation Stages – Key Activities Tooloutlinesthefourstagesofimplementationandprovidesexamplesofkeyactivitiesateachstage.Italsoprovidesatemplateforstakeholderstoanalysetheirownprogressonthekeyactivitiessuggested,aswellasanyadditionalactionstheyidentifyspecificallyfortheirintervention(s).

Click here to access the tool on the Centre for Effective Services’ website:http://effectiveservices.org/resources/article/implementation-stages-key-activities

Enablers and BarriersImplementation Science has highlighted a number of factors which increase the probability ofanyinterventionbeingsuccessfullyimplemented.Thediagrambelowindicatestenofthesemostcommonly-seenfactorsandindicatesatwhichstageofimplementationtheyrequiremostattention.Thesefactorsaregivenavarietyofnamesintheliterature,includingdriversandfacilitators,butforsimplicity,thisGuidewillrefertothemasimplementation ‘enablers’

Implementation Enablers Stages of Implementation1

Exploring&Preparing

2 Planning&Resourcing

3 Implementing&Operationalising

4 Full

ImplementationStakeholderconsultationandbuy-inLeadershipResourcesImplementationplanImplementationteamStaffcapacityOrganisationalsupportSupportiveorganisationalcultureCommunicationMonitoringandevaluationDatainformedimprovementcycles

ImplementationEnablersbyStageofImplementation[14]

Researchhasalsopointedtoanumberoffactorswhichhindertheimplementationprocess.Theseareknownas implementation ‘barriers’. These includealignmentproblemswith funding cycles,resistancetochangeandvestedinterests.Takingstepstoavoidorovercomethesebarriers,wherepossible,atanearlystageofimplementationisveryimportantforsuccessfulimplementation.

http://effectiveservices.org/resources/article/implementation-stages-key-activities


Context for ImplementationImplementationScience indicatesthe importanceofthecontext inwhich interventionsare implementedand used [19]. Examples of factors that influencecontextinclude:

• Providers’perceptionsofanintervention• Patients’needs• Relationships,networksandcommunications• Structuralcharacteristicsoftheenvironment• Localandnationalpolicies• Culture.

By nature, implementation is inseparable from context. This means that contextual influencesexplain a lot of the variation in implementation success [19]. For example, if an interventionrequires thepurchaseofnewequipment,but theexternal contextmeans funding isnot readilyavailable,thechancesofsuccessfulimplementationarereduced.

Assuch,itisimportanttotakecontextintoaccountanddesignguidelinessothattheycanleveragefavourablecontextualfactorsandovercomeunfavourableones.Thiscanbedifficult,ascontextualfactorsareoftenchangeableandtransient.

However,contextcanalsobe influencedandmalleabletochange [21]. Implementationenablerssuchasasympatheticculture;strongleadership;staffsupportsuchascoachingandmentoring;andwell-designedfeedbackandevaluationmechanisms,canallhelptoinfluencecontextinapositiveway.

Contextcanbedescribedas‘thesetofcircumstancesoruniquefactorsthatsurroundaparticularimplementationeffort’.Thiscanrefertoboththewider,systemiccontext,aswellasthespecificsettinginwhichaspecificinterventionwillbeimplemented[20]


Strategies for ImplementationFor some time, there has been evidence that tailored implementation strategies improveimplementation success [22]. Implementation Science is now identifying what strategies andactivitiesmaybeusedtotargetspecificenablersandbarriersofimplementation.Thesestrategiescanbeeithertop-downorbottom-up:

Top-Down Implementation Strategies Bottom-Up Implementation StrategiesA linearapproachwherestrategiesare ledfromacentralsource.

Adecentralised approachwhere strategiesareinitiatedbystakeholdersatcommunity/locallevel.

Examples:• Distributeeducationalmaterials• Conductongoingtraining• Mandatechange

Examples:• Captureandsharelocalknowledge• Organise clinician implementation

teammeetings

The recent Expert Recommendations for ImplementingChange (ERIC) project has sought to gather togetherimplementationstrategiescommonlyusedbythosetryingto successfully implement an intervention [23]. This canbeusedbyimplementersasa‘menu’ofoptions,wherebythey can choose strategies and activities based on whatwould be most suitable and effective in their specificcontext.

Unfortunately,thereiscurrentlylittleevidenceonhowtosystematicallychoosestrategies[24],soanelementoftrialanderrorshouldbeexpectedandtolerated.

ClickheretoaccesstheExpertRecommendationsforImplementingChangelistof73 implementation strategies [23,pp.8-10]

Stage 1: Exploring and Preparing


Stage 1: Exploring and Preparing

In stage 1 of implementation, the needs of stakeholders are assessed, the reason/rationale for developing the guideline is clarified, and the scope of the guideline is determined. It involvesexploring thecontext inwhich implementationwill takeplace,andtherangeofpossibleactionsthatwillsuitthiscontext.Forguidelinedevelopment,thisstagetypicallyinvolvesdecidingontherangeofclinicalquestionstobeincludedintheguideline,i.e.thescopeoftheguideline.Specificactivitiestobecarriedoutinthisstageare:

• Stakeholderengagementplanning• Assessingneedsandtheevidencebase• Assessingthefit,feasibilityandimplementabilityofpotentialrecommendations• Specifyingoutcomeswhichtheguidelineseekstoachieve• DevelopingaTheoryofChangeandLogicModel.

Itisworthrememberingthatwhiletheseactivitiesaremostsuitableduringstage1,theymaystillbeusefulforGuidelineGroupsatotherstagesofimplementation.

Thekeytoolsthatcanbeusedduringthisfirststageofimplementationare:• Stakeholderengagementtool• Hexagontoolforassessingthereadinesstoimplement• Logicmodeltemplate.

Stakeholder Engagement PlanningIn the development, implementation and evaluation ofguidelines,theinvolvementofstakeholders:

• Helpscreateawareness• Generatesbuy-in• Identifiesandacknowledgesanyresistance• Aidsintheassessmentofneed,fit,feasibility,capacity

andreadiness.

The pyramid shown overleaf indicates four potential levels of engagement with stakeholders.GuidelineGroupsshouldconsideratwhichleveltoengagewithkeystakeholders.Theupperlevelsof thepyramidaremore likely to achieve true levelsof engagement,whereby stakeholders feeladequatelyconsultedandarewillingtobuy-intotheintervention.However,theupperlevelsofthepyramidalsohaveahigherresourcerequirementintermsofeffortandcost.

Stakeholdersareanyonewhoisaffectedbyorisinvolvedinthedevelopmentofanddeliveryofguidelines/projects.Theyincludepatients,public,clinicians,managers,professionalbodies,unions,educatorsandpolicymakers.


Collaborate Two-wayengagementwithjointlearning,decision-makingandactions;

partnerintheprocess

Involve Two-wayengagementwithlimitstotheirresponsibility;

theyarepartoftheprocess.

Consult Morelimitedpartoftheprocess–involved,butroleislimited–stakeholdersareasked

questionsandtheyrespond

Inform Usingpullcommunication(informationismadeavailableandonusisonstakeholdertofind

it)orpushcommunication(informationisactivelybroadcastedtostakeholders)

Levels of Stakeholder Engagement. From Centre for Effective Services, 2017 [25]

Effor

tN

umbers

Itisalsoimportanttorecognisethat,whenimplementingguidelines,groupsofstakeholdersmaybeverydiverse,dependingonspecificlocalcontexts.ThismeansthatGuidelineGroupsmayfocusonhigh-levelstakeholders,anddetailedstakeholderengagementplanningmaybemoreeffectiveatalocallevel.

The Stakeholder Engagement Tool,developedbytheCentreforEffectiveServices,helpsthoseimplementingapolicyorprogrammetoplanforandmanagetheprocessofengagingwithkeystakeholders.Itsetsouttasksandquestionsforstakeholderidentification,analysisandmapping.Italsoprovidesatemplateandchecklisttohelpdevelopastakeholderengagementplan.

Click here to access the Stakeholder Engagement Tool on the Centre for Effective Services website: http://effectiveservices.org/resources/article/stakeholder-engagement-tool

Public InvolvementTheNCEChaspublishedaFrameworkandToolkit forPublic Involvement inClinicalEffectivenessProcesses in2018,which is availableon theNCECwebsite:http://health.gov.ie/national-patient-safety-office/ncec/public-involvement-framework/. The term ‘public’ includes a wide range andvarietyof individuals, aswell as groups and/ororganisations. These includepeoplewhouse, orhaveusedhealthcareservices,carersandfamilymembers,parents,organisationswhorepresentpatients, patient support groups, charities that represent specific health conditions, individualswithaninterestinatopic,andmembersofthegeneralpublic[26]

The public are partners in the use of clinical guidelines. Their involvement at all stages of theplanninganddevelopmentprocessisintegraltothefeasibility,needsassessmentandsustainabilityof the intervention. Public involvement in clinical effectiveness processes strengthens publicparticipationinhealthcaredecision-makingandbringspublicknowledgeandexperiencetotheseprocesses.

http://effectiveservices.org/resources/article/stakeholder-engagement-tool

http://health.gov.ie/national-patient-safety-office/ncec/public-involvement-framework/



The NCEC Framework and Toolkit for Public Involvement inClinical EffectivenessProcessesoutlines thepractices thatmaybeundertakento involvethepublic inclinicaleffectivenessprocessesand includes theNCECvalues forpublic involvement,whichapplytoengagementwithallstakeholders:

• Dignityandrespect• Support• Transparencyandopenness• Learningandresponsiveness• Inclusivity,fairnessanddiversity• Sustainability• Collaborationandpartnership.

Needs AssessmentPrior toguidelinedevelopmentand implementation,aneedsassessmentshouldbecarriedouttoidentifythegapbetweenwhatiscurrentlyinplaceandwhatisdesirabletohaveinplace,inadditiontoanyvariation inpractice.Thesegapsshouldbeassessed at multiple levels (patient, provider, organisation,system).Needsshouldalsobeassessedfromtheperspectiveof the stakeholders (both individuals and organisations)whowillbedirectlyinvolvedinimplementation.

“Clearly, improving the health and wellbeing of patients is the mission of all healthcare entities, and many calls have gone out for organisations to be more patient centred… Consideration of patients’ needs and resources must be integral to any implementation that seeks to improve patient outcomes” [20, p.7].

Thebasicquestionstobeansweredbyaneedsassessmentare[27]:• Whatarethegaps?• Whatiscausingthem?• Whatcanwedotofixit?

A needs assessment should come very early in the guideline development and implementationprocess,anditissometimesconsideredapre-implementationactivityoranecessaryfirststep.

The Hexagon Tool is a planning tool used to conduct a needs assessment and evaluateimplementation readiness for interventions during the initial stages of implementation. It helpsguidelinedevelopersandimplementerstobroadlyconsidersixfactorsthathelptodeterminelevelsofneedandindicatewhereinitialimplementationeffortswouldbemostimpactful.Thesixfactorsare:Need; Fit; Resource Availability; Evidence; Intervention Readiness; and Capacity to Implement.

TheHexagonToolisalsoaveryusefulwayforGuidelineGroupstobeginconsideringoutcomesandcanbeconsideredasanintroductoryexerciseindevelopingalogicmodel.

To access the Hexagon Tool, click here or see Tool 1.

A Needs assessmentclarifiestheextenttowhichneeds,aswellasbarriersandfacilitatorstomeetthoseneeds,areaccuratelyknownandprioritisedbyanorganisationorgroupofpeople.


Identifying OutcomesImplementation outcomes are changes resulting fromdeliberate and purposive actions to implement newtreatments, practices, and services. They are distinct fromserviceoutcomesandpatient/clientoutcomes,andtheyservethreemainpurposes:

a) Theyareindicatorsofimplementationsuccessb) Theyhighlightimplementationprocessesc) They can serve as intermediate outcomes for desired

serviceorclientoutcomeswhichmayfollow(becauseaninterventionisunlikelytobeeffectiveunlessimplementedwell).

Thediagrambelowpresentsataxonomyofimplementationoutcomes,serviceoutcomesandclientoutcomes.Thisisfollowedbyfurtherdetailsonimplementationoutcomes.

Implementation Outcomes

AcceptabilityAdoption

AppropriatenessCosts

FeasibilityFidelity

PenetrationSustainability

ServiceOutcomes

EfficiencySafety

EffectivenessEquity

Patient-centerednessTimeliness

ClientOutcomes

SatisfactionFunction

Symptomatology

Taxonomy of Outcomes. From Proctor et al., 2010 [28]

Outcomesareintendedorunintendedchangesthatoccurasaresultofimplementinginterventions.Thesechangescanoccuratthelevelofindividuals,groups,organisationsorpopulation,andcanoccurintheshort-,medium-orlong-term.


Implementation Outcome

Description Other terms

Acceptability Theperceptionamongstakeholdersthataninterventionisagreeable,palatableorsatisfactory.

Content;comfort;credibility

Adoption Theinitialdecisiontoemployanintervention. Uptake;utilisation;intentiontotry

Appropriateness Theperceivedfit,relevanceorcompatibilityofanintervention.

Perceivedfit;compatibility;suitability;practicability

Feasibility Theextenttowhichaninterventionmaybecarriedoutwithinagivensetting.

Actualfit;suitabilityforeverydayuse;practicability

Fidelity Thedegreetowhichaninterventionwasdeliveredasdescribed.

Deliveredasintended;adherence;integrity;qualityofdelivery

Cost Thecostimpactoftheimplementationactivities;bothduetothecostofdeliveringanintervention,andthecomplexityoftheimplementation.

Cost-effectiveness;cost-benefit;marginalcost

Penetration Theintegrationofaninterventionintoaservicesettinganditssub-systems.

Institutionalisation;spread;serviceaccess

Sustainability Theextenttowhichaninterventionisinstitutionalisedwithinaservice’songoingoperations.

Maintenance;continuation;durability;incorporation;integration

Tips for identifying desired outcomes: • A range of outcomes relating to implementation, service delivery and clients should be

considered.• Identifywhichoutcomesareachievableintheshort-term,andwhicharemoremedium-or

long-termoutcomes.• Forclinicalguidelines,wellthought-outandarticulatedoutcomesareusefully includedina

logicmodel,formingoneofthefirststepsinalogicmodel’sdevelopment.Beforegoingstraighttothelogicmodel,theHexagon Tool(Tool1)helpstostartthinkingaboutdesiredoutcomes.

• Frame and label outcomes in the correct language. They should indicate a change from acurrentposition,ratherthanjustanactivity,outputordecision.Thediagramoverleafprovidessomeexamples of incorrectly labelledoutcomes andhow they canbemore appropriatelyframed.


Standardisationofcharts

Teamwork

E-learningprogrammemandatory

Chartsarestandardisednationally.

Enhancedteamworkacrosshealthcareteams.

E-learningprogrammeincorporatedintomandatorytrainingrequirements.

Developing a Logic Model The potential usefulness of guidelines shouldbe determined with reference to a clearlyarticulated description of how theywill bringabout a change. A Theory of Change makesthisexplicit,by indicatingwhyproviding inputXshouldleadtoachangeinoutcomeZ,bywayof output Y. This theory should be evidence-based,andtracehowthe inputs,outputsandoutcomes are conceptually and practicallylinked.

Input X Output Y Outcome Z

Theoverall TheoryofChangecanbe simplybrokendown intoa seriesof ‘if-then’ relationships,wherebyeachstep/relationship shouldbe informedbyexistingevidenceabouthowneedsariseandhowchangeisachievedinprevioussteps/relationships.

AnexampleofaTheoryofChangefortheMobilisationofVulnerableAdults,Ontario(MOVE-ON) [29] study is provided below. This clearly details a number of steps and expected relationships,whereby investment intrainingand infrastructurecaneventually leadto improvedoutcomesforclientsandservices.

Managementandstaffvalue

mobilisationamongpatients

Staffaregiventhetoolstoincreasepatientmobility

Patientsareassessedfortheirmobility

needs

Staffdeveloplocalised

mobilisationstrategies

Patientsgetexerciseduringtheir

hospitalisation

↓Lossofmusclestrength

↓Depression

↓Delirium

↑Rateofdischarge

↑Independentfunctioning

↓Hospitalcosts

Investmentintrainingandinfrastructure

If – Then If – Then If – Then If – Then If – Then

Theory of Change for the Mobilisation of Vulnerable Elders, Ontario (MOVE-ON) study (created by CES based on [29])


Theseriesof‘if-then’relationshipsandoutcomesthatexpresstheprogramme’stheoryofchangeformtheunderlyingbasisofaLogic Model.ThelogicmodelfurtherdescribesandelaboratesontheTheoryofChange,allowingstakeholderstosystematicallyworkthroughconnectionsbetweentheessentialcomponentsofguidelines,usuallyonasinglepage.

Guidelinesdesignedusingalogicmodelcanhelptoachievedesired results by encouraging a focus onoutcomes fromthestart,makingtheconnectionsexplicitandensuringthatthereisevidencetosupporttheconnections.

It is important to remember that using a logic modeldoes not take away from the need for flexibility orresponsiveness.Alogicmodelisastatementofintentanddevelops through a live and iterative process rather thana one-off event. This means it can adapt to unexpectedevents, takeadvantageofemergingopportunities,andbecreativeinmeetingchallenges.

However,toomanychanges,especiallyifthesearereactive,canunderminethevalueofthelogicmodel.Therefore,alogicmodel,particularlyifverycomplex,isbestseenasahigh-levelstatementwhichrequiresaseparate,andmoredetailed,implementationplan(tobedevelopedinstage2).

Monitoring and Evaluation

Situation Analysis Inputs Activities/

OutputsShort-term Outcomes

Evidence

Long-term Outcomes

Thebasicoutlineofalogicmodelisshownabove.ItshouldbecompletedbyGuidelineGroupsinthefollowingsequenceofsteps:

1. Situation Analysis: Consider the context andwhat the opportunities, problems and needsin relation to theguidelineare.The informationcontained in thisboxcandrawheavilyontheneedsassessment.Answering the followingquestionswillhelp todescribe thecurrentsituation:• Whyistheguidelineneeded?• Whatisthesituationandissue(s)?• Whataretheneedsofpopulationandtargetgroups?• Whatarethestrengthsandweaknessesofcurrentprovision?• Wherearethegaps?

Benefits of using a Logic Model:• Provides coherence across

complextasks• Helps differentiate between

‘what we do’ (outputs) and‘results/changes’(outcomes)

• Keepsfocusonsharedgoals• Improvesevaluationandwhat

variablesgetmeasured


• Whatdoweneedtoimprove?• Whatarethesocio-economicinfluences?

2. Outcomes:Asdescribedabove, those responsible fordevelopmentand implementationofguidelinesshouldaskwhatspecificchangesaredesiredintheshort-,medium-andlong-term.Thesecanincludechangesinknowledge,behaviour,practice,decision-making,policies,socialaction,condition,statusetc.Long-termoutcomesarethedesiredend-result,andshort-termoutcomesmayormaynotbecumulativestepsorcontributionstothelong-termoutcomes.

3. Outputs/Activities:Thesearekeyareasofworkthatwillhelptoachievethedesiredoutcomes.Theyincludespecifictargets(e.g.,numbersofpeopletrainedorqualified,resources,reports,newprocessesandstructures),aswellasclearstatementsabout:• Whatwillbedone?(typesofactivities)• Whowillbereached?(clients,providers,beneficiaries,otheragencies)• Whereitwillhappen?• Whenandhowoftenhowitwillhappen?• Howitwillhappen?

Itisusefultobeasclearaspossibleaboutyourthinkingregardingthechoiceofactivitiesandinclude specific targets for numbers to be reached and frequency of activities, wherepossible.

4. Inputs:Thisinvolvesbeingclearaboutwhatresourcesareneededtocarryouttheactivities/outputs identified. As such, inputs essentially enable outputs. Examples of resources thatcanbeemployed include staff,equipment,buildings, technology, informationsystems,andsupportstructures.Thelimitednatureofresourcesmeansit is importanttotrytoleverageorre-organiseexistingresourcesasmuchaspossibleandincludeanyadditionalcostsintheguideline’sBudgetImpactAnalysisandeconomicevaluation.Ifcostsareconsideredunrealisticornotcosteffective,thentheactivities/outputssectionmayhavetoberevisitedandrevisedaccordingly.

5. Monitoring and Evaluation: This involves assessing the extent towhich an intervention isworking towards theoutcomes stated. In the logicmodel, it is important to consider howinformationwillbecollected,interpretedandreported.Itisalsoimportanttoconsidertargets,metrics,andKeyPerformanceIndicators(KPIs),aswellasbaselinesandbenchmarks,whichcanprovidesignsofprogress.

Morethanothersectionsofthelogicmodel,themonitoringandevaluationsectionshouldbehigh-level,withspecificconcernsaboutdataandmethodologydealtwithindetailduringplanningforMonitoringandEvaluation,whichiscoveredinmoredetailinlatersectionsofthisGuide.

6. Evidence: Thisshouldunderpinallaspectsof the logicmodeland involves takingdataandevidencefromresearch,audit,experience,policy,consultation,andongoingmonitoringandevaluationprocessesto:• Informunderstandingofproblems


• Identifydesiredoutcomes,andhowtheymaybeeffectivelyachieved• Devisingwaysofmonitoringandevaluatingprogress.

Itisimportanttoconsidermultipleformsofevidencehere,includingpeer-reviewedresearch,independentreports,casestudies,greyliterature,auditdataandpracticewisdom.Informationcontained inthe logicmodelcanbeunderpinnedbyanyoftheseformsofevidence, if theevidenceisofhighquality.

Tips for developing a logic model: • Whilealogicmodelshouldbereadfromlefttorightoncecompleted,itismostlydeveloped

from right to left, beginning with outcomes (after completing the situation analysis) andworkingbackthroughactivities/outputsandinputs.

• Thoughitisoftendifficulttobeprecise,being as concrete as possible,intermsoffiguresandtargetslisted,isbetterforplanning,implementation,accountabilityandevaluationpurposes.

• Outcomes inserted into a logic model can be clearly grouped bywhethertheyarerelatedtoimplementationoutcomes,serviceoutcomesorclientoutcomes

• List any anticipated inputs and discuss any issues arising. If you are intending to workin partnership, for example, what would you need to consider in terms of planning orimplementation?

• Workalreadydoneonthe Hexagon Tool and outcomes can form the basis for development of a logic model

Toaccessablank version of the Logic Model Tool,whichGuidelineGroupscaneditandfillinfortheirownguidelines,click here or see Tool 2.

Whenan intervention is particularly complex, itmaybeuseful forGuidelineGroups to createaseriesoflogicmodels.Thismayhelptobreakdowntheoveralllogicmodelintoamoremanageable,clear,conciseandrelevantwayforthoseresponsibleforimplementingspecificrecommendationsorworkinginspecificcontexts.Logicmodelscanbebrokendowninthefollowingways:

1. Multiple logic models,witheachpertainingtoadifferentelementoftheintervention.Thismaybeparticularlyhelpfulinthecaseofclinicalguidelines,whichoftencontainamultitudeofdifferentrecommendationsthatarenotalwayseasytogrouptogether.

2. Nested Logic Models,witheachbeingapplicableatdifferent levelsofservicedelivery(e.g.national,hospital,service).Thismayhelptoincreaseclarityateachlevel,aswellasallowingguidelinegroupstotailorandadaptthelevelofdetailincludedineachlogicmodel.


Macro level, e.g. National

Institution level, e.g. Hospital

Unit level, e.g. Service

The following page contains a worked example of a logic model, created by the GuidelineDevelopmentGroupresponsiblefortheupdateoftheNational Clinical Guideline No. 6: Sepsis Management in 2018.


Mon

itorin

g an

d Ev

alua

tion

•Th

eAn

nualSep

sisRep

ortw

illre

view

HIPEda

tato

assessfrequ

encyand

cha

racteristi

csofsep

sispresentati

ons,and

sepsisassociated

morbidityand

mortalityinIrelan

d.•

SepsisAu

dits,K

eyPerform

anceIn

dicators,and

balan

cing

mea

sures.

Logi

c M

odel

for N

ation

al C

linic

al G

uide

line

– Se

psis

Man

agem

ent

Situ

ation

Ana

lysi

s•Sepsisisalead

ingglob

alhea

lth&

finan

cialburde

n•Irish

dataon

sepsis(201

6):

o14

,804

casesofsep

sis

oIn-hospitalm

ortalityrate18.5%

oCriticalcareho

spita

lmortality

rate31.3%

o67

%in

crea

sein

docum

ented

sepsiscasess

ince201

5o

50%ofb

eddaysu

sedby

patie

ntsw

ithinfecti

on/sep

sis

diagno

siso

Sepsiscontrib

utesto

25%

ofa

llho

spita

ldeaths

•Allsep

sispati

entssh

ouldbe

provided

with

thebe

stopp

ortunity

tosu

rvivesepsis

•Prob

lemsw

ithaccuracyofHIPE

recordingofse

psiscases

•New

internati

onaldefi

nitio

nof

sepsis;Sep

sis-3

•Va

riatio

ninpracti

ce•Clinicaldecision

supp

orttoo

ls(CDS

T)–upd

ateofexisting

Sep

sis

Form

sand

new

Sep

sisFormsfor

paed

iatrics,obs,G

Ps,residen

tial

care

•Nee

dforS

epsis

Predicti

onM

odel

Inpu

ts•Gu

idelineDe

velopm

ent&

Im

plem

entatio

nGrou

p•SepsisStee

ringCo

mmittee

•HS

E:QID

•HS

E:NAS

/HPO

/ICT

•Nati

onalSep

sisTe

am•SepsisAD

ONfo

reachHo

spita

lGrou

p•SepsisCo

mmittee

s–Local&

Hospita

lGroup

Level

•Ho

spita

lman

agem

ent

•Labo

ratory&Nati

onalM

edical

Labo

ratoryIn

form

ation

System

(Med

LIS)

•Med

ical&Nursin

glead

inevery

hospita

l•Alliedhe

althcareprofessiona

ls•SepsisCh

ampion

sinPrim

aryCa

re

•Re

siden

tialcarestaff

•Und

ergrad

uatecolleges–

nursin

gan

dmed

ical

•Stati

stician

•An

nualSep

sisSum

mit

•An

nualSep

sisRep

ort

•Sepsispo

rtalonHS

Eweb

site

•CD

STs

•Lactatepo

int-o

f-care(POCT

)de

vices

•Do

H–NCE

C/HR

B-CICE

R

Activ

ities

/Out

puts

•Co

mmun

icati

on&eng

agem

ent

with

keystakeh

olde

rs•

Dissem

inati

onand

commun

icati

onofn

ewse

psis

defin

ition

s&re

commen

datio

ns•

Developm

ento

fsep

sisedu

catio

nprog

rammes(a

dult,pae

ds,o

bs,

GP)

•Ro

utine

sepsisscreen

ingfor‘at

risk’and

suspectedsepsiscases

•De

liveryofapp

ropriate

treatm

enta

ndtimelyescalatio

nofcare(ifre

quire

d)•

Deliveryofedu

catio

nprog

rammes

oAv

ailableon

HSELand

as

eLea

rningprog

ramme

oGrou

pAD

ONsa

vailableto

provideed

ucati

onatlocallevel

oEd

ucati

onre

sourcesa

vailable

onSep

sisW

ebsite

•De

velopm

ento

fCDS

Tforp

aeds,

obs,GPsand

resid

entia

l•

Developm

ento

fpati

ent

inform

ation

leafl

ets&

postersfo

rweb

site

•Bu

sinessc

aseforp

aediatric

AD

ON

•De

velopm

ento

fsep

sisaud

ittoolsa

ndsc

hedu

leofa

udit

•Nati

onalaud

itsperform

edby

SepsisAD

ONs

•Bi-ann

ualSep

sisSteering

Committee

mee

tings

•SepsisAD

ONsliaising

betwee

nlocalsite

s&Nati

onalSep

sis

Team

•De

velopm

ento

fmon

thlyKPIsfor

seps

is•

Educati

onofH

IPEcode

rs

Out

com

esSh

ort-t

erm

out

com

esIm

plem

enta

tion

Out

com

es•

Sepsisgu

idelinewidely

dissem

inated

&in

usein

all

clinicalareas/areasofcare

•Allstaffun

derstand

thene

w

sepsisde

finition

sand

its

man

agem

ent

•Pathwayso

fcarearefeasible

•Prog

rammeofedu

catio

nestablish

edfo

rund

ergrad

uate

andqu

alified

staff

•Ed

ucati

onprogram

mede

emed

man

datoryata

nati

onallevel

Serv

ice

Out

com

es•

Useofa

ppropriateCDS

Ttoaid

timelydiagno

sisand

treatm

ent

•CD

STwidelyavailableinall

clinicalareasto

aiddiagn

osis&

treatm

ent

•Sepsisde

finition

swidelyused

&

documen

tedbyallstaff

•Increa

sedaccuracyofcod

ingfor

allsep

siscases

•Be

tterc

ommun

icati

onacrossa

llhe

althcarete

ams&

professiona

ls•

Decrea

sedaverageLeng

thof

Stay(LOS)fo

rpati

entswith

se

psis

•Im

proved

recogn

ition

and

treatm

entforpati

entsin

all

clinicalse

tting

s•

Discha

rgefollo

w-upprovided

for

patie

ntsw

ithse

pticshock

Clie

nt O

utco

mes

•De

crea

sedmortality&m

orbidity

associated

with

sepsis

•De

crea

sedincide

nceofse

psis

andsepti

cshock

•Re

ducti

onofa

dverseoutcomes

Long

-term

out

com

esIm

plem

enta

tion

Out

com

es•

Nati

onalado

ption

ofg

uide

line

with

fide

lity

•Useofthe

nati

onalguide

lines

isem

bedd

edacrossa

llservice

area

s•

Allspe

cialtie

sarere

presen

tedon

theNati

onalSep

sisTe

am•

Paed

iatricADO

Nin

post

•NOCA

nati

onalaud

itofIC

U

patie

ntsw

ithse

pticshock&

databa

sein

place

Serv

ice

Out

com

es•

Decrea

sedaverageLO

Sforsep

sis

patie

nts

•Safera

ndequ

itablesepsiscare

fora

llpa

tientsw

ithse

psis

•Im

proved

accuracyofre

cording

ofse

psiscases

Clie

nt O

utco

mes

•De

crea

sedmortality/morbidity

associated

with

sepsis

•Im

proved

qua

lityoflifefo

rpa

tientsfollowingsepsis

•Im

proved

pati

enta

ndfa

mily

satisfacti

onwith

carereceived

Evid

ence

: Systemati

creview

oflite

ratureonde

tecti

onand

man

agem

ento

fsep

sis;Interna

tiona

lguide

lines;T

hirdIn

ternati

onalCon

sensusDefi

nitio

nsfo

rSep

sisand

Sep

ticSho

ck(JAM

A20

16);Su

rvivingSepsisCa

mpa

ign:

Internati

onalGuide

lines

forM

anagem

ento

fSep

sisand

Sep

ticSho

ck:2

016;Expertreview;B

udgetimpa

ctana

lysis

;Ann

ualSep

sisRep

orts;H

IPEda

ta.

Stage 2: Planning and Resourcing

28 Implementation Guide and Toolkit for National Clinical Guidelines28 Implementation Guide and Toolkit for National Clinical Guidelines

Stage 2: Planning and ResourcingIn stage 2 of implementation, the foundation is laid for effective implementation. This stageinvolvesplanningforimplementationinmoredetail,anticipatingpotentialimplementationissues,costing the implementation plan and submitting the Budget Impact Assessment as part of theannualserviceplanningprocess.Specificactivitiestobecarriedoutinthisstageare:

• Assessingimplementationreadiness• Assessingenablersandbarriers• Implementationplanning• Expandingthe initialGuidelineDevelopmentGroupto include implementationteam(s)and

developinfrastructureforimplementation• Developingleadershipforimplementation• Monitoringandevaluationplanning• Trainingandcapacitybuilding• Sustainabilityplanning.

Itisworthrememberingthatwhiletheseactivitiesaremostsuitableduringstage2,theymaystillbeusefulforGuidelineGroupsatotherstagesofimplementation.

Thekeytoolsthatshouldbeusedduringthissecondstageofimplementationare:• Implementationenablersandbarriersassessmenttool(Tool3)• Implementationplantemplate(Tool4)• MonitoringandevaluationofimplementingNationalClinicalGuidelines–PlanningTool(Tool

5).

Assessing Implementation ReadinessEvidence shows that attempts to implement newinterventions often fail because those leading theimplementationfailtoestablishsufficientreadinessforthechange[30]

Implementation readiness in healthcare settings isdependentonanumberofkeyfactors:[20, 31,32]

• Psychological and behavioural readiness inindividuals,teamsandorganisations–staffshouldbeindividuallyandcollectivelyprimed,motivated,andtechnicallycapableofexecutingchange.

• General organisational/structural capacitytosuccessfullyimplementanyinnovation–existingstaff,ICTinfrastructure,humanresourcesandproceduresetc.

• Organisational/structural capacity that is intervention-specific – specific training, resourcesandpoliciesetc.

• Leadership engagement– leaderscancreatereadinessbyconsultingallstakeholders inthedecision-makingprocess,bygivingcleardirectiononthechange,andbyacknowledgingandvalidatinganyconcerns.

• Securingaccess to resourcesneededtoimplementguidelines–theimplementationplanmustbecosted,andaBudgetImpactAssessmentcarriedout,tobesubmittedthroughtheserviceplanningprocess.

Implementation Readinessreferstotheextenttowhichorganisationsandindividualsareboth‘willing’to,and‘capable’of,implementinganyspecificintervention[32]

29Implementation Guide and Toolkit for National Clinical Guidelines 29Implementation Guide and Toolkit for National Clinical Guidelines

Assessingandunderstandingimplementationreadinesscanhelpidentifybarriersandfacilitatorstochangeandinformimplementationplanning.However,readinessatonestageofimplementationdoes not ensure readiness for the next. Thismeans that assessing readiness is an ongoing anditerativeprocess, that shouldconsidernewchallengesandaddress themas theyarise [32] This requiresfeedbackandinputfromstakeholdersatlocallevelstogetanaccuratepictureofchangingcontextsandcircumstances.

Resources and strategies to help assess and build implementation readiness:• The Hexagon Toolisusefulforassessingneedsandreadiness,andimplementationplanning:

ClickhereorseeTool1

• Normalization Process Theory (NPT):o Toolkitforthinkingthroughpotentialimplementationproblems: http://www.normalizationprocess.org/npt-toolkit/o Murray et al. (2010) paper, titled ‘Normalisation Process Theory: A framework for

developing,evaluatingand implementingcomplex interventions’,whichoutlines fourcomponentsofreadiness,andalistofquestionsforimplementersthatarerelevanttoeachcomponent:

http://www.lenus.ie/hse/handle/10147/142753

• The Checklist to Assess Organizational Readiness (CARI) created by Barwick (2011)addresseseightdifferentfactorsrelatingtoreadinessinorganisations:

http://www.effectiveservices.org/resources/article/checklist-to-assess-organisation-readiness

• Other resources and measures for assessing implementation readinessareavailableandlistedontheCaliforniaEvidence-BasedClearinghousewebsite:

http://www.cebc4cw.org/implementing-programs/tools/measures/

http://www.normalizationprocess.org/npt-toolkit/

http://www.lenus.ie/hse/handle/10147/142753



http://www.cebc4cw.org/implementing-programs/tools/measures/


Assessing Enablers and Barriers

Implementation Enablers

Stakeholder consultation and buy-in

Involvingclinicians,thepublic,patients,administratorsandpolicymakers,amongothers,asearlyaspossibleandthroughoutthedevelopmentandimplementationprocesshasseveralbenefits:ithelpscreateawareness;itgeneratescontinuedbuy-in;itidentifiesandacknowledgesanyresistance;anditaidsintheassessmentofneed,fit,feasibility,capacityandreadiness.TheNCECPublicInvolvementFramework[26]includestoolstoassistinvolvingthepublicinclinicaleffectivenessprocesses.

Leadership Havingatleastonechampionimprovesthelikelihoodofimplementationsuccess[22].Championsareearlyadoptersofchange,providingvisionandsupporttoindividualstaffandtheorganisationasawhole.

Resources Itisimportanttohaveanaccuratecalculation(aspartofaBudgetImpactAnalysis)ofthecostsandcosteffectivenessofdesigning,implementinganddeliveringaguideline.Oncecosthasbeendetermined,securingappropriateresources,wherenecessary,throughtheserviceplanningprocessisrequiredforsuccessfulimplementation.ToolstoassistwithBudgetImpactAssessmentandEconomicEvaluationareavailableontheNCECwebsite:http://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/ncec-processes-and-templates/

Implementation teams

Implementationteamsoverseeandattendtomovingguidelinesthroughthestagesofimplementation.Theseteamsmakeuseofactivestrategiestodrivesuccessfulimplementationandshouldbemadeupofmembersfromarangeofdisciplinarybackgroundswithspecificexpertiseinrelevantinterventionsorinimplementingchange.TheremaybesignificantoverlapinmembershipbetweentheoriginalGuidelineDevelopmentGroupandtheImplementationTeam(s).Inadditiontoanationalimplementationteam,furtherimplementationteamsmayalsobeestablishedtodriveimplementationinspecificsettings.

Implementation plan

Allowingtimeforplanninghowguidelineswillbeimplementediscrucialinensuringsuccessfuloutcomes.Byinvolvingmultiplestakeholdersinplanningatanearlystageoftheimplementationprocess,potentialhurdlescanbemoreeasilyanticipatedandovercome.Italsoincreasesaccountabilityamongrelevantstakeholders.Animplementationplanincludesthespecificactionstoimplementtheguidelinerecommendations,detailsofwhoisresponsible,timelinesfordeliveryandoutcomemeasurements.

Staff capacity Thosewhoareresponsiblefortheimplementationofaspecificinterventionmusthavethecapacitytodeliverit.Therefore,developingandkeepingthiscapacityispivotalinensuringdesiredoutcomesareachieved.Staffcapacitycanbeattainedthrough:carefullyallocatingstaff;deliveringqualitytraining;andprovidingongoingsupport,suchascoachingandmentoring.

http://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/ncec-processes-and-templates/



Implementation Enablers

Organisational support

Supportiveorganisationalstructures,systems,policiesandproceduresthatalignwithandsupportguidelinesareimportantforsuccessfulimplementation.Examplesinclude:proceduresforinternalgovernanceanddecision-making;andhumanresourcestomanageresistancetochange.

Supportive organisational culture

Organisationalcultureincludesthenorms,valuesandbeliefsthatexistandgovernbehaviourwithinanorganisation.Itisnecessarytocreateasupportiveculturesothatspecificinterventionscansuccessfullybecomeembeddedintheorganisationthrough:championscommunicatingastrongvisionforchange;supportingpositiverolemodels;andongoingtrainingandsupport.

Communication Ongoingandopencommunicationwithandbetweenstaffiscrucialinsuccessfulimplementationforseveralreasons:ithelpsmotivatestaffandovercomeresistance;providesamechanismforfeedbackanddealingwithconcerns;andhelpstobuildtrustandmorale.

Monitoring and evaluation

Collectingandinterpretinginformationaboutimplementationandotherkeyoutcomesisessentialindeterminingwhetherguidelinesarebeingsuccessfullyimplemented.Thisinformationhelpstoinformfutureactionsandincreaseefficiency.

Learning from experience

Theuseofdataandinformationtoimprovebothspecificinterventionsandtheguidelineimplementationprocessisvitalforimplementationsuccess.Doingthiseffectivelyhelpstoidentify‘quickwins’,buildcredibilityandsupport,andenablescontinuousimprovementcycles.

Implementation Barriers

External environment

Theexternalenvironment canreduceimplementationsuccessifexistingstructuresarenotinlinewithguidelines.Forexample,shortpolicyandfundingcyclesmayinterferewiththeimplementationprocessbymakingitmoredifficulttosecurelong-termengagementandbuy-in.

Resistance to change

Resistancetochange fromthosedeliveringspecificinterventionscanundermineimplementationeffortsandreducetheprobabilityofsuccess.Resistanceiscommonlygeneratedif:stakeholdersfeeltheyhavenotbeenconsulted;changesareimplementedbeforestakeholdersareready;implementationisperceivedasoccurringthroughcoercionorcontrolfromleadership;theorganisationalcultureisnotalignedwiththeguideline;orappropriategovernancestructurestosupportguidelineimplementationarenotputinplace.

Vested interests Vestedinterestsofstaff,managers,lobbygroups,andotherprofessionalbodiesmayinterferewiththeimplementationprocessiftheyareincongruentwiththeguidelines.Thiscanoccurthroughstakeholdersblockingtheimplementationprocessoralteringitinanew,lessproductivedirection.


Implementation Enablers and Barriers: Assessment ToolTheCentreforEffectiveServiceshascreatedabespoketoolforstakeholdersinvolvedindesigningand implementing clinical guidelines and other policies, procedures, protocols and guidelines(PPPGs),toassessenablersandbarriers.ThistoolisbasedontheConsolidatedFrameworkforImplementationResearchandtheBehaviourChangeWheel.Thetoolgeneratesconsiderationofstructuralandpsychologicalenablersandbarrierstoimplementationinahealthcontext.

To access the tool, click here or see Tool 3.

Implementation PlanningAllowingadequateandappropriatetimeforplanninghowclinicalguidelineswillbeimplementedis a crucial implementation enabler. Devising an implementation plan enables those driving thechangetomapouttheimplementationprocessandprovideacourseofactionforanychallenges.Research shows that implementation is likely to be more successful if this planning is doneconcurrentlywiththedevelopmentofguidelines,ratherthanaftertheyhavebeendeveloped[9]

The following steps help to prepare the implementation plan and should be retained by thosedeveloping/implementingguidelines:

• Assessmentofimplementationreadiness• Developmentofaone-pagelogicmodel,includingsituationanalysis,inputs,activities/outputs

andoutcomes• Assessmentofenablersandbarriers• Identificationof specificbehaviour changeor change in currentpractice required (i.e.who

needstodowhatdifferentlyinorderforthisrecommendationtobeimplemented?)• Clearlydocumentingbaseline/currentstatusandanyassumptionsbeingmade• IncludinganyadditionalresourcesrequiredintheBudgetImpactAssessment.

A comprehensive Implementation Plan should [8]:üDetailtheimplementationobjectivesüOutlinetasks and activities necessaryforimplementationüIdentifywho is responsibleforthedeliveryofactivitiesüOutlinetime-frames and milestonesüConsiderrisks andstrategiestomanagethese risksüIdentifymonitoring and reporting processes.

It is importantthat implementationplanningshould includepublic involvementandengagementwithmultiplestakeholderstosecurebuy-inandensurethattheplanconsidersmultipleviewpoints.The plan should also remain live throughout the implementation process and be revisited andrevisedregularlythroughoutallimplementationstages.

AnimplementationplanmustbeincludedinpublishedNCECguidelines.Thetemplateprovidesanexampleofatoolthatcanbeusedforimplementationplanning,promptingGuidelineGroupstolayouttheimplementationtasks(in the form of specific actions);whichguidelinerecommendation(s)thesetasksreferto;whichgroup/unit/organisationhasleadresponsibilityforthetask;anindicative


timeframeforcompletion;andsomedetailonexpectedoutcomesandhowtheywillbeverifiedormeasured.Itcanalsoincludeimplementationenablersandbarriers,someofwhichwillbecommontomultiplerecommendations.

Guideline recommendation or number(s)

Implementation enablers/barriers/gaps

Action/intervention/task to implement recommendation

Lead responsibility for delivery of the action

Timeframe for completion

Expected outcome and verification Year 1 Year 2 Year 3

ImplementationPlanningTools• TheabovetemplateiscontainedinanImplementation Planning Tool (Tool 4) Completed

NCEC guidelines must include an implementation plan.Thetoolalsohelpsstakeholderstoconsider implementation team processes; dissemination and communication strategies;anddevelopmentofspecificimplementationtoolsandresources.

To access the Implementation Planning Tool, click here or see Tool 4

• Thefollowingpagescontainaworked exampleofanimplementationplancompletedbytheOvarianCancerGuidelineDevelopmentGroup.

• Click here to access aGagliardi et al. (2015) paper ‘Developing a checklist for Guideline Implementation Planning’ whichcontainsauseful checklist to help stakeholders consider different aspects of implementation planningforclinicalguidelines[9,pp.5-6]

https://implementationscience.biomedcentral.com/articles/10.1186/s13012-015-0205-5

34 Implementation Guide and Toolkit for National Clinical Guidelines34 Implementation Guide and Toolkit for National Clinical GuidelinesIm

plem

enta

tion

Plan

– O

varia

n Ca

ncer

Gui

delin

e

Guideline

recommen

datio

nor

numbe

r(s)

Implem

entatio

nen

ablers/

barriers/gap

sAc

tion/interven

tion/taskto

im

plem

entrecom

men

datio

nLead

respon

sibilityfo

rde

liveryofth

eactio

nTimeframefor

completi

onExpe

cted

outcomean

dverifi

catio

n

Year1

Year2

Year3

Reco

mm

enda

tion

#1Inpati

entswith

suspectedovarian

carcinom

a,a

combina

tionof

tran

sabd

ominal

andtran

svaginal

ultrasou

ndsh

ould

beperform

edand

interpretedusingthe

IOTA

simplerules

incon

junctio

nwith

clinicalassessm

ent.

Enab

ler:

Nati

onalCan

cerS

trategy

Recommen

datio

n#1

4(Cap

italPlan).

Barr

ier:

Accessto

tran

svaginal

ultrasou

ndequ

ipmen

t.

•Assessth

eavailabilityof

ultrasou

ndequ

ipmen

t,includ

ingsterilisatio

neq

uipm

ent.

•Assesswaitin

gtim

esfo

rte

sts

HSEClinical

Prog

rammefor

Radiolog

y

XO

utco

me:

Allw

omen

with

suspectedovariancancerwill

havetimelyaccessto

tran

svaginalultrasou

nd,

carriedou

tbyexpe

rienced

personn

el.

Tran

svaginalultrasou

ndwillprovide

greater

sensitivityfo

rdiagn

osingovariancancer.

Verifi

catio

n:Co

mpleted

assessm

ento

fequ

ipmen

tand

waitin

gtim

es.

Securere

sources/fund

ing*fo

r•

Equipm

ent:Ad

ditio

nal

ultrasou

ndequ

ipmen

t+

replacem

ent/m

ainten

ance.

(Thisa

ction

willbeba

sedon

theresultsofthe

equ

ipmen

tassessmen

t)

NCC

P&Hospital

Grou

psX

Verifi

catio

n:Eq

uipm

entinplace.

Accessto

diagn

ostic

s.

Enab

ler:

Nati

onalCan

cerS

trategy,

Recommen

datio

n#1

0,16

&50

(radiolog

ytraining

,consultantstaffi

ng,w

orkforce

plan

ning

).

Barr

ier:

Limite

davailabilityof

approp

riatelytraine

dstaff

.

Assessth

ecurren

tnum

ber

ofpersonn

elwith

specialist

training

inso

nograp

hy.

HSEClinical

Prog

rammefor

Radiolog

y

XVe

rifica

tion:

Completed

workforceassessm

ent.

Securere

sources/fund

ing*fo

r•

Training

:Spe

cialisttraining

ofra

diolog

ystaff

.•

Staffi

ng:P

ersonn

elwith

specialisttrainingin

sono

grap

hy.

(Thisa

ction

willbeba

sedon

theresultsofthe

workforce

assessmen

t).

NCC

P&Hospital

Grou

ps&HSEClin

ical

Prog

rammefor

Radiolog

y

XVe

rifica

tion:

Staff

inplace.

Training

provide

d/staff

training

records.

*Fun

ding

requ

irem

ents

incl

uded

in B

udge

t Im

pact

Ass

essm

ent,

for s

ubm

issio

n in

the

HSE

finan

cial

esti

mat

es/s

ervi

ce p

lann

ing

proc

ess

35Implementation Guide and Toolkit for National Clinical Guidelines 35Implementation Guide and Toolkit for National Clinical GuidelinesGu

ideline

recommen

datio

nor

numbe

r(s)

Implem

entatio

nen

ablers/

barriers/gap

sAc

tion/interven

tion/taskto

im

plem

entrecom

men

datio

nLead

respon

sibilityfo

rde

liveryofth

eactio

nTimeframefor

completi

onExpe

cted

outcomean

dverifi

catio

n

Year1

Year2

Year3

Reco

mm

enda

tion

#2CT

thorax,abd

omen

an

dpe

lviswith

oral

andintraven

ous

contrastis

recommen

dedfor

thestagingofovaria

ncancer.

Reco

mm

enda

tion

#4Forp

atien

tswith

ahigh

suspicionof

relapseofovaria

ncancereith

erclin

ically

orbiochem

ically,CT

thorax,abd

omen

and

pe

lvisisrecommen

ded

asth

efirstline

im

agingtest.

Enab

ler:

Nati

onalCan

cerS

trategy

Recommen

datio

n#1

4(Cap

italPlan).

Barr

ier:

Accessto

Com

puterised

Tomog

raph

y(CT).

•Assessth

eaccessto

CT.

•Assessth

ewaitin

gtim

esfo

rCT

HSEClinical

Prog

rammefor

Radiolog

y

XO

utco

me:

Allp

atien

tswith

ovaria

ncancerwillhavetim

ely

accessto

CT.

Allp

atien

tswith

ahighsuspicionofre

lapseof

ovariancancerwillhavetim

elyaccessto

CT.

Verifi

catio

n:Co

mpleted

assessm

ento

fCTeq

uipm

enta

nd

waitin

gtim

es.

Securere

sources/fund

ing*fo

r•

Equipm

ent:Ad

ditio

nalC

Ts.

Thisactio

nwillbeba

sedon

theresultsofthe

equ

ipmen

tas

sess

men

t

NCC

P&Hospital

Grou

ps&HSEClin

ical

Prog

rammefor

Radiolog

y

XVe

rifica

tion:

Equipm

entinplace.

Accessto

diagn

ostic

s.

Reco

mm

enda

tion

#3IftheCT

is

inde

term

inate,

patie

ntss

hould

bedisc

ussedata

multid

isciplin

aryteam

mee

ting.

Enab

ler:

Nati

onalCan

cerS

trategy

Recommen

datio

n#1

3multid

isciplin

aryteam

mee

ting.

Barr

ier:

Availabilityofim

agingfor

discussio

natm

ultid

isciplin

ary

team

mee

ting.

Prep

arati

onofa

Stand

ard

Ope

ratin

gProced

ure(SOP)fo

rovariancancerm

ultid

isciplin

ary

team

mee

ting.

NCC

P&Hospital

Grou

psX

Out

com

e:

Patie

ntsd

iagn

osed

with

ovaria

ncancer

willhavetheirc

aseform

allydisc

ussedata

multid

isciplin

aryteam

mee

ting.

Verifi

catio

n:KP

I12Ca

ncerStrategy:Ensurethatpati

ents

haveth

eirc

asediscussedatam

ultid

isciplin

ary

team

mee

ting.

SOPisde

velope

dan

davailable.

*Fun

ding

requ

irem

ents

incl

uded

in B

udge

t Im

pact

Ass

essm

ent,

for s

ubm

issio

n in

the

HSE

finan

cial

esti

mat

es/s

ervi

ce p

lann

ing

proc

ess.

For

full

impl

emen

tatio

n pl

an, s

ee p

ublis

hed

guid

elin

e.

36 Implementation Guide and Toolkit for National Clinical Guidelines36 Implementation Guide and Toolkit for National Clinical GuidelinesG

over

nanc

e an

d Im

plem

enta

tion

Team

Gov

erna

nce:Governa

nceofth

egu

idelineisprovided

byamultid

isciplin

aryStee

ringGrou

pchairedbyth

eDirectorofthe

NCC

P.M

embe

rshipinclud

esre

presen

tativ

esfrom

allrelevant

disciplin

esand

thechairsofe

achCa

ncerGuide

lineGrou

p.The

group

mee

tsqua

rterlyto

assessp

rogress,provide

oversightand

lead

ershipto

guide

linegrou

ps,add

ressanyque

riesa

ndto

en

sureth

egu

idelinede

velopm

enta

ndim

plem

entatio

nprocessu

sesa

neviden

ce-based

app

roach.

TheSu

rgicalGyn

aecologyOncolog

yClinicalLea

dsgroup

wasestab

lishe

din201

2toensurethatth

esevencentresd

esigna

tedforS

urgicalG

ynae

cologyOncolog

ybu

ildonrobu

stlo

calclin

ical

governan

cearran

gemen

ts,toop

erateasacoh

esivena

tiona

lclin

icalnetworkforc

linicalaud

it,sh

aringofgoo

dpractic

ean

dprob

lemso

lving.

Impl

emen

tatio

n Te

am:A

Steering/Im

plem

entatio

ncommittee

hasbee

nsetu

pbyth

eNCC

Pan

dtheHS

Etoguide

theim

plem

entatio

nofth

isGu

ideline.The

Steering/Im

plem

entatio

nGrou

pinclud

esallrelevantstakeh

olde

rsin

clud

ing–pa

tholog

ists,ra

diolog

ists,gyn

aecologyoncolog

ists,palliativ

ecare,h

ospitalm

anagers,nursin

g,IC

T,inform

atics,lab

oratoryscienti

sts,pati

ents

andarepresen

tativ

efrom

theNCC

P.Im

plem

entatio

nwillbesupp

ortedbyth

eorganisatio

nsth

atarere

presen

tedon

theGu

idelineGrou

p,whichin

clud

etheFaculty

ofR

adiologists,Royal

CollegeofS

urgeon

sinIre

land

,The

FacultyofP

atho

logistsR

oyalCollegeofP

hysic

iansIrelan

d,Nati

onalLea

dClinicianforH

ered

itaryCan

cera

ndPati

entA

dvocateGrou

ps.

Diss

emin

ation

and

com

mun

icati

on p

lan

TheGu

idelinewillbecirculated

and

diss

eminated

throug

htheprofessio

naln

etworkswho

partic

ipated

indevelop

ingan

dreview

ingthisgu

ideline(HSEClin

icalProgram

mesin

Surgery/

Radiolog

y/Patholog

y/Palliati

veCare,RCS

I,Faculty

ofS

urgery/Rad

iology/Patho

logy,H

SEPati

entF

orum

,IrishCa

ncerSociety,C

ancerC

areWeste

tc.).The

guide

linewillalso

beavailablevia

theNCE

Can

dNCC

Pweb

sites.

Adissem

inati

onstrategyhasbee

nprep

ared

and

theGu

idelinewillbeoffi

ciallylaun

ched

and

circ

ulated

toallrelevantfa

cultiesand

collegesfordiss

eminati

onto

theirm

embe

rs.The

NCC

Pwillco-ordina

tewith

HSECom

mun

icati

onstodistrib

ute,sh

arean

ddissem

inatethroug

hthemed

ia(H

SEBroad

cast,H

ealth

Matt

ers,and

Twitter).The

implem

entatio

nofth

eGu

idelinewill

alsobesupp

ortedbycom

mun

icati

on,trainingan

ded

ucati

on.

Impl

emen

tatio

n to

ols:

The

follo

wingim

plem

entatio

ntoolsa

reavailableon

theNCC

Pweb

siteathttps://w

ww.hse.ie

/eng

/services/list/5/cancer/nccp/

•GP

Referralguide

linean

dreferralfo

rm:

oOvaria

ncancerGPRe

ferralGuide

lineforsym

ptom

aticwom

eno

Ovaria

ncancerGPRe

ferralfo

rmfo

rsym

ptom

aticwom

en•

Book

let-NCC

P(201

8)Sexua

lwellbeing

afte

rbreasto

rpelviccancertreatm

ents-agu

ideforw

omen

•Algo

rithm

sforclin

iciansavailableinth

egu

ideline:

oStagingalgo

rithm

forp

atien

tswith

suspectedovariancancer

oStagingalgo

rithm

forp

atien

tswith

suspectedrecurren

ceofo

varia

ncancer

•Cliniciangu

idan

cedocum

ent-Hea

lthServiceExecutiv

eGu

idan

cefo

rdecon

taminati

onofsem

i-criti

calu

ltrasou

ndprobe

s;se

mi-invasivean

dno

n-invasiv

eultrasou

ndprobe

s(https://

www.hse.ie

/eng

/abo

ut/w

ho/qid/nati

onalsafetyprog

rammes/decon

taminati

on/ultrasou

nd-probe

-decon

taminati

on-guida

nce-feb-17

.pdf)

•HS

Epo

licytoguide

staff

-Nati

onalCon

sentPolicy20

17https://w

ww.hse.ie

/eng

/abo

ut/w

ho/qid/other-qua

lity-im

provem

ent-p

rogram

mes/con

sent/

•Patie

ntinform

ation

oncancergen

eticshttps://w

ww.can

cergen

etics.ie

/•

Training

and

resourcesinEviden

cebased

Practi

ce

https://www.hse.ie/eng/services/list/5/cancer/nccp/

https://www.hse.ie/eng/about/who/qid/nationalsafetyprogrammes/decontamination/ultrasound-probe-decontamination-guidance-feb-17.pdf

https://www.hse.ie/eng/about/who/qid/nationalsafetyprogrammes/decontamination/ultrasound-probe-decontamination-guidance-feb-17.pdf

https://www.hse.ie/eng/about/who/qid/other-quality-improvement-programmes/consent/

https://www.cancergenetics.ie/


Establishing Implementation TeamsImplementation teams are groups of stakeholdersthatoverseeandattendtomovingguidelinesthroughthe stages of implementation. They are establishedto make it happen, i.e. actively use strategies andsupportstofacilitateimplementation.

Implementationteamsaretypicallymadeupof3-12people,andthecompositionofthegroupisextremelyimportant. It is possible to repurpose existingGuidelineDevelopmentGroupswhenformingapost-publication implementation team, but the followingpointsshouldbeconsidered:

• Diversity–doestheteamhaveanappropriatebalanceofperspectives,trainingandexpertise,experience,relationshipsandpriorities?

• Decision-making authority – the implementation team should containmemberswho havetheirowndecision-makingauthorityorhavedirectaccess todecision-makingauthority, sothatdecisionscanbemadeinatimelymanner

• Knowledge –theimplementationteamshouldcontainmemberswhohaveexpertknowledgeofspecificinterventionscontainedwithinguidelines,datause,implementation,andsystemschange.

Itisimportantthatthereis somedegreeofoverlapinmembershipbetweenGuidelineDevelopmentGroups and implementation teams, as implementation needs to be considered throughout allstagesofguidelinedevelopment.Itisrecommendedthatthereisan‘ImplementationLead’ontheGuidelineDevelopmentGroupfromthebeginning,toensurethatguidelinerecommendationsareimplementableandtocoordinatethedevelopmentoftheimplementationplan.

It is worth noting that one implementationteam may not be sufficient to implementguidelines at a national level. In this case,it might be appropriate to establish aninfrastructure of linked implementation teams to encourage greater integration andcoherenceinlargesystems.Teamscanoperateat different levels (e.g. national, hospitalgroup, individual hospital, community) orteams can work to implement differentrecommendations contained in clinicalguidelines.

Key implementation team functions: üMove guidelines through the stages of

implementation üEnsurefidelitytointerventionscontained

withinguidelinesüIdentifybarriersandfindsolutionswhereneededüIdentify enablers and leverage themifpossibleüEnsureBudget Impact Assessmentissubmittedtotheserviceplanningprocess


üPutimplementation infrastructureinplaceüEngagewithstakeholdersandcommunitiesüBuild cross-sector collaboration to ensure service partners are aligned with new ways of

workingüWorkwithotherteamstomonitor progress üUse data tomakedecisionsandsupportimplementationcapacityüEnsuredecisionsarepurposefulandplanned

Developing Leadership for ImplementationThereisbroadconsensusontheimportanceofleadershipforeffectiveimplementation.Thisisduetothepotentialforleadershiptoinspireandmotivatestafftoadoptandsustaintheattitudesandbehaviouralchangesnecessaryforeffectiveimplementation[33]

Researchlinkingleadershipandthequalityofhealthcareindicatesaneedforacollectivenetworkofleaders,includingpractitionersatalllevels,distributedthroughoutthehealthcaresystems[34] andpublicinvolvement.Thismayrequiredistributionanddecentralisationofleadershippowertowhereverexpertise,capabilityandmotivationsitinthesystem.

Creatinganorganisationalculturewhereleadersflourishhasbenefitsforbothstaffandtheleadersthemselves:

• If leaders and implementers create positive, supportive environments for all practitioners,thosepractitionersthencreatecaring,supportiveenvironmentsforpatients

• Wherethereisacultureofcollectiveleadership,practitionersarelikelytointervenetosolveproblems,toensurequalityofcareandtopromoteresponsible,safeinnovation.

The following table provides examples of different leadership activities which can supportimplementation[35]:

Relations-oriented behaviours

Change-oriented behaviours Task-oriented behaviours

• Communicatewithpractitionersaboutclinicalissues

• Recogniseeffortstochange• Providereminders• Encourageandsupport

collaborationwithspecialistsandinter-professionals

• Supportchangevisiblyandsymbolically

• Demonstratecommitmenttochange

• Reinforcevisionandgoalsofchange

• Understanddifficultieswithchange

• Advocateforchangeinternallyandexternally

• Advocateforadditionalresourcesorreorganisationofexistingresourcesinternallyandexternally

• Conductregularleadershipmeetings

• Clarifyrolesandresponsibilities

• Monitorperformanceandoutcomes

• Modifycare-plansanddocumentation

• Procureresources,education,trainingandpoliciestoreflectchange

While individual members of Guideline Groups may not be in high-level leadership positionsthemselves, they can seek to influence those who are, and be champions for the guidelinesthemselves.


Monitoring and Evaluation PlanningNationalClinicalGuidelinesendorsedbytheMinisterforHealtharemandatedforimplementationinthe Irishhealth system.Accordingly,theNCECguidelinedevelopmentprocessrequiresmonitoringandauditcriteria,includingKeyPerformanceIndicators(KPIs),tobeincludedineachguideline.

• Monitoringistheroutineandsystematiccollectionofinformationagainstaplan.Itmakesuseofexistingdataandinformationaboutinputs,outputsandoutcomes,oraboutoutsidefactorsaffectingtheorganisationorproject,toinformimprovement.

• Evaluationisaplannedinvestigationofaproject,programme,orpolicyusedtoanswerspecificquestions,oftenrelatedtodesign,implementation,andresults(causeandeffect).

• Clinical or Healthcare Audit is aprocess to improvepatient careandoutcomes involvingadocumented,structuredandsystematicreviewandevaluation,againstclinicalstandards,orclinicalguidelines,and,wherenecessary,actionstoimproveclinicalcare.

Clinicalauditispartoftheclinicalgovernanceagendaandisintendedtoprovidetheevidencefor assuring the quality of clinical care and helping to bring about improvements wherenecessary.

Clinicalauditisacyclicalprocess,recognisedashavingthefollowingelements:• acommitmenttoqualityimprovementandlearning• measurement–measuringaspecificelementofclinicalpractice• comparison – comparing results with an accepted benchmark, these are national or

internationalstandards,orclinicalguidelines• evaluationandaction– reflecting theoutcomeofaudit andwhere indicated, changing

practiceaccordingly(sometimesreferredtoas‘closingtheloop’).

Information and toolstohelpguidelinedevelopersthinkaboutmonitoringandauditcriteriaareavailablefrom:

• The National Clinical Effectiveness Committee guideline development manual http://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/ncec-

processes-and-templates/

• The National Clinical Effectiveness Committee website http://health.gov.ie/national-patient-safety-office/ncec/

• The HSE Quality Improvement Division website https://www.hse.ie/eng/about/who/qid/measurementquality/clinical-audit/

For implementationtobemeasuredaccurately,all threeof theabovemechanismsmaybeusedwithdifferentlevelsofemphasis,dependingonthecontext.Thereisnosinglemeasurementtypethatcomprehensivelymeasuresallelementsofimplementation,andahybridmethodologymayberequired.Currently, implementationofNCECNationalClinicalGuidelinesismonitored through theHSE Performance Assurance Reports, compliance with the National Standards for Safer BetterHealthcareand alignmentwith the clinical indemnity scheme[36]

ThepurposeofthissectionisnottofocusonmethodologiesorKPIsformonitoring,evaluationandaudit.Instead,theremainderofthissectionwillfocusonplanningformonitoringandevaluation,particularly when considering how to monitor whether the guideline has been successfully implemented. Accordingly, the table overleaf provides a series of prompts and questions thatguidelinegroupscanusetoguideplanningformonitoring,evaluationandaudit.




https://www.hse.ie/eng/about/who/qid/measurementquality/clinical-audit/



Planning for Monitoring and Evaluation – Prompts and Questions

1. What is the purpose(s) of our evaluation? Why do we want to do it?

• Isitabouteffectiveness,efficiency,economy,relevance,implementation,processand/orimpact?

• Isitaboutpopulationchangeorperformanceaccountability?

2. What is the evaluation question(s)? What will we monitor and evaluate?

• Whatisthetheoryofchangeunderpinningtheguidelinesorspecificinterventionstobeevaluated?

• Fromthelogicmodelfortheguideline,whatwillbeprioritisedformonitoringandevaluation?

3. Who will use the learning from the evaluation? How can we involve them from the start?

• Whatindicatorswillweusetoaddressdifferentaudiences?

• Whatmethodswillweuseintheevaluationtoinvolvekeystakeholders?

4. What resources and expertise do we have for our evaluation? What resources do we have/will we need, including outside support?

• Whatisthebudgetfortheevaluation?• What areourexperiencesofevaluation?• What areourskillsandwhatarethegapsthatneed

tobefilled?

5. What is our plan for operationalising the evaluation (tasks, responsibilities, timescales etc.)? How will we do it? When will we do it?

• Whowillmanageandcoordinatetheevaluation?• Howlongwillittake?Dowehaveascheduleof

activities?

6. What are the main challenges? Who will do it, and do they have the right skills?

• Whatstaffwillbeinvolvedandwhattrainingisrequired?

• Howwillwesecureactiveparticipation,engagement,motivation?

7. What is our plan to disseminate and use our learning from the evaluation? What will we do with the information we get?

• Whowillwriteupthefindingsandhelpwithinterpretation?

• What otherstrategiesareneededtodisseminateandsharelearningwithdifferentstakeholders?

• Howwillthefindingsbeusedtoinformqualityimprovements?

Monitoring and Evaluation of Implementation: Planning Tool TheCentreforEffectiveServiceshascreatedabespoketooltohelpGuidelineGroupstothinkaboutandplan for monitoring and evaluation of the implementation process.Thistoolshouldbeusedatanearlystageofguidelinedevelopmenttoensurethatmonitoringandevaluationareembeddedintotheimplementationprocess.

To access the Monitoring and Evaluation of Implementation Planning Tool, click here or see Tool 5.

Involving relevant stakeholders is a crucialpartof themonitoringandevaluationprocess– theyshould be consulted with at all stages of developing and implementing clinical guidelines. Thisis toensure that specific responsibilitiesofall those involvedcanbeclarifiedandagreedbefore


monitoringandevaluationcommences,andthattheaddedburdenofcollectingandrecordingdataisfeasibleandmanageable.Todeterminewhichstakeholdersshouldbeinvolvedinthemonitoringandevaluationofclinicalguidelines,itisimportanttoestablish[37]:

1. Whoisinvolvedinthedeliveryofthecareorservice?2. Whoisinreceiptof,usesorbenefitsfromthecareorservice?3. Whohastheauthoritytosupportimplementationofanyidentifiedchanges?

IndicatorsItisalsoimportanttoconsiderwhatindicatorscanbefeasiblyandaccuratelyusedtomonitorandevaluateimplementationoutcomes.Toensurethateffortstocollectdataarestreamlinedandthatthedataisrelevant,theseindicatorsshouldbeaction-focused, important, measurable and simple.

Action-Focused Mustbeusedtoinformfuture

actions

Measurable Collectingandanalyzingthe

informationmustbepossiblewithmethodsandresourcesavailable

Important Aswithoutcomes,onlymeasure

whatmatters

Simple Thelanguagemustbeaccessible,

clearandconcise

A number ofQuality andPatientSafetyPerformanceIndicatorsthatmeasureimplementationandthe impact of NationalClinicalGuidelinesalreadyexistandarespecifiedintheHSEServicePlan:https://www.hse.ie/eng/services/publications/serviceplans/national-service-plan-2018.pdf

When deciding how to monitor and evaluate implementation of clinical guidelines, existingindicators and data collectionmechanisms should be used where available. Other useful typesof data collection methods may also already be in place, such as patient satisfaction/patientexperiencesurveys,evaluation,qualityindicators,auditandresearch.

The HSE Measurement for Improvement Team combines expertise in quality improvement,statisticalanalysisandqualitativeresearchwithclinicalexperience.Theteamprovidesanumberofusefultools and resourcesontheirwebsite,aswellastraining and adviceonhowtoanalyseandpresentinformationgatheredfrommonitoringandevaluationprocesses.

To access the tools, resources, training and advice, see the HSE Measurement for Improvement Team website: https://www.hse.ie/eng/about/who/qid/measurementquality/measurementimprovement/measurement-for-improvement-team.html

Additional information and tools for clinical auditareavailableinthefollowingdocuments:• A Practical Guide to Clinical Audit (HSE) https://www.hse.ie/eng/about/who/qid/

measurementquality/clinical-audit/

• Improvement Knowledge and Skills Guide (HSE) https://www.hse.ie/eng/about/who/qid/improvement-knowledge-and-skillsguide/

https://www.hse.ie/eng/services/publications/serviceplans/national-service-plan-2018.pdf

https://www.hse.ie/eng/about/who/qid/measurementquality/measurementimprovement/measurement-for-improvement-team.html

https://www.hse.ie/eng/about/who/qid/measurementquality/measurementimprovement/measurement-for-improvement-team.html



https://www.hse.ie/eng/about/who/qid/improvement-knowledge-and-skillsguide/


Training and Capacity BuildingOneof themost important factors inbuilding leadership inanorganisationorsetting isbuildingandmaintainingstaffcapacity.Oneaspectof this;coachingandmentoring– iscovered indetailinstage3.Therearealsoseveralotherkeymechanismstobuildstaffcapacityforimplementation[22]:

• Assignment/recruitmentofstaff• Training

Whenplanning for implementation,GuidelineGroups should seek to highlight the staff trainingandcapacity-buildingneedsthatareassociatedwiththeguideline.Whilenotnecessarilyexpectedtodesigntheseproceduresandprocesses,itisimportantthatthesegroupsconsiderhowtheymaybedeveloped.Again, internallyavailableresourcesshouldbeleveraged,wherepossible,andanyadditionalresourcesrequiredshouldbeincludedintheguideline’sBudgetImpactAnalysis.

Assignment/recruitment of staffStaffwhowillbeinvolvedinimplementingclinicalguidelinesshouldhavetheappropriateskillsandknowledgetodoso,ortheabilitytolearnthese.Effectiveassignment/recruitmentofstaffrequiresspecifyingwhattherequiredskillsandabilitiesforthespecificinterventionare;thedevelopmentof methods for identifying these skills and abilities in practitioners; and criteria for selectingpractitionerswiththoseskillsandabilities.Theseaspectsshouldbe included in jobdescriptions,staffinductionandcontinuousprofessionaldevelopment.

TrainingStaffshouldbefacilitatedtodeveloptheirknowledge,experienceandskillsofspecificinterventionsthrough effective and timely training. Training programmes should provide knowledge relatedto the theory and underlying principles and values of the intervention; introduce the keycomponentsofpractices;andprovideopportunitiestopracticenewskillsandreceivefeedbackina safe, supportiveenvironment. The content and formatof trainingmay varydependingon theinterventionandshouldbedevelopedwiththeneedsofstaffandpatientsinmind.

Sustainability PlanningGuidelines aimed at improvinghealthcare need to be sustainedfor improved outcomes to bemaintained. Essentially, sustainabilitymeans that one year or longer afterimplementation, at a minimum, thesituation has not reverted to theold way of working, or old level ofperformance.

Forinterventionscontainedwithinguidelinestobesustainable,theyshouldbeabletowithstandchallengesandvariation,evolvealongsideotherchangesandcontinuetoimproveovertime.Thereisatensionbetweenneedingtomaintain‘fidelity’toaspecificinterventionandneedingtoevolveinachanginghealthcarecontext.Changestoimplementationplansmayneedtobemadesothatan intervention can continue to be used in practice andmaintain the benefits for patients andcommunities.

TheUnitedKingdom’sNationalHealthServicedefinessustainability as achieved when ‘not only have theprocess and outcome changed, but the thinking andattitudes behind themare fundamentally altered andthesystemssurroundingthemaretransformedaswell.Inotherwords,thechangehasbecomeanintegratedormainstreamwayofworkingratherthansomething“addedon”’[38,p.6]


To maximise the potential for sustainability, sustainability planning should commence near thebeginningof theguidelinedevelopmentand implementationprocess.However, it isusefulatallstagesof implementation, and sustainabilityplans shouldbe revisitedat severaldifferentpointssothatsustainabilitycanbemonitoredovertime.Throughcontinuouslyassessingandidentifyingpotentialbarrierstosustainability,strategiescanbeputinplacetoanticipateandaddresspotentialimplementationproblems.

The following tableoutlines somekeyquestions to consider in relation todifferent elementsofsustainability[38,39]:

Key elements of Sustainability

Questions

Planning for sustainability

• Issustainabilityplanninganactivecomponentofallstagesofimplementation?

• Canexistingservicesintegrateaspecifiedintervention?

Credibility of the evidence

• Arebenefitstoserviceusers,staffandorganisationsvisible?• Isthereevidencethatthistypeofchangehasbeenachieved

elsewhere?

Seeking commitment and support

• Whatleaders/managerssupporttheimplementationofguidelines?• Aretheguidelinescongruentwithotherpolicyobjectives/contextsat

thetime/future?

Engagement and partnerships

• Isthereevidencethatappropriateandinfluentialstakeholders,includingthepublic,areaccepting/supportiveofguidelines?

Programme champions

• Aretherelocal‘champions’topromotethevalueofguidelinesandisinterestlikelytobeongoing?

Fit with organisation • Areguidelinescontributingtotheoverallorganisationalaims?• Is‘fit’assessedinanongoingmanner?

Building capacity – organisational and community

• Arestaffinvolvedintheimplementationofguidelines?• Isthereacapacity-buildinginfrastructuretoensuretheskills

necessarytocontinueimplementationwillexist/remain?

Infrastructure for sustainability

• Havecrucialelementsofguidelinesbeenembeddedintopoliciesandprocedures?

• Arenewrequirementsbuiltintojobdescriptions?

Adaptability • Dostructuresandpoliciesallowsomeflexibilityandevolution,asrequired,tomaintainandimproveoutcomes?

Evaluation • Areoutcomesmeasuredtodeterminecontinuedbenefit?• Isevidenceusedtodevelopandimproveguidelines?• Aretherefeedbackmechanismsinplacetocommunicateresultsand

initiateaction?

Funding • Isfundingavailabletosupportimplementationtoalevelthateffectsaremaintained(orincreased)?

• Whatexistingresourcescanbeleveragedorreorganisedtosupportimplementation?

Policy/economic environment

• Whatchangesareoccurringinthepolicyandeconomicenvironmentthatmayhaveanimpactonguidelineimplementation?


Sustainability Planning ToolTheUnitedKingdom’sNationalHealthServicehasproducedaSustainability:ModelandGuide,whichacts as a diagnostic tool to help plan for sustainability and monitor progress over time, and as a guide offering practical advice on how to maximise success at sustaining change

It identifies a range of factors that influencesustainability,including:• Credibilityofthebenefitsofanintervention• Effectiveness of the system to monitor

progressandmeasurechange• Staff involvement and training to sustain

theprocess• Seniorandclinical leadershipengagement

andsupport• Alignment with organisational strategic

aimsandculture.

Guideline Groups are not necessarily expected to design these systems and processes.Instead, they should aim to signal the importance of these factors, identify needs, cost theimplementation process, and influence high-level decision-makers where possible. This pointmaybeparticularlyrelevantforstakeholdersandimplementersatamorelocallevel.

Click here to access the NHS Sustainability Model and Guide: https://improvement.nhs.uk/resources/Sustainability-model-and-guide/

https://improvement.nhs.uk/resources/Sustainability-model-and-guide/


Stage 3: Implementing and Operationalising


Stage 3: Implementing and OperationalisingIn stage 3 of implementation, guidelines are implemented in clinical and healthcare settings for the first time. Essentially,guidelinesareput intopracticebypractitionersandorganisationalsupportsandfunctionsbegintooperatetohelp implementation.Guidelineswillbesignedoffatthispoint,however, stakeholders cancontinue tobe influential in their implementation throughhighlightingneeds,takingupmembershipofimplementationteams,andactingaschampionsfortheguidelines.

Specificactivitiestobecarriedoutinthisstageare:• Maintainingcommunicationwithstakeholdersandsecuringcontinuedbuy-in• Providing professional development opportunities and support, such as coaching and

mentoring• Ongoingmonitoringofimplementationoutcomes,serviceoutcomesandclientoutcomes• Usingdataandfeedbackmechanismstoinformongoingimprovements• Adaptingimplementationplansforlocalsettingswhereappropriate.

Itisworthrememberingthatwhiletheactivitieshighlightedaremostsuitableduringstage3,theymaystillbeusefulforGuidelineGroupsatotherstagesofimplementation.

Maintaining Communication Ongoing communication between implementation teams, practitioners, champions, publicrepresentatives,andallotherrelevantstakeholdersisanimportantenablerofimplementationforseveralreasons:

• Communicatingavisionforchangehelpstomotivatestaffandovercomeresistancetochange• Communicationprovidesanimportantmechanismforobtainingfeedback• Opencommunicationhelpstobuildtrustandteamworkbetweenvariousstakeholders,teams

andorganisationsresponsibleforimplementation.

Both formal and informal communication are important, with networking and ‘water cooler’conversationshavingasmuchpotentialtochangeindividualbehaviourasformalbroadcasts.Thefollowingstrategiesrelatingtocommunicationcanallcontributetomoreeffectiveimplementation[20]:üAssimilatingnewstaffandmakingthemfeelwelcomeüFosteringpeercollaborationandopenfeedbackandreviewacrosshierarchicallevelsüClearcommunicationofguidelines’purposeandgoalsüUseofchampionstoencouragecohesionbetweenstaffandpositiveinformalcommunication

aboutguidelines.


Coaching and MentoringEvidence suggests that training aloneis insufficient to change the skills ofprofessionals.Ameta-analysisof research ineducation showed that with training alone,only 5-10% used the new practice; thisincreased to 80-90% when supplementedwithcoaching[40].Accordingly,coachingandmentoring are increasingly being used as amethod of supporting and building capacityamongprofessionals.

Building quick and accurate use of new skills and behaviours in the real world is challenging.Coaching andmentoringoffer additional benefits to traditional training approaches andprovideopportunitiesforstafftoreceivesupportandassistanceinthedevelopmentofskillsalignedwithspecificinterventions.Benefitsinclude[41,42]:

• Helpingstafftoadjusttoandimplementchange• Decreasing frustration by focusing on helping staffmeet performance goals and reducing

burnout• Motivatingandhelpingstafftobuildfluencyandaccuracywitheffectiveskills• Providingtimetoproblem-solve,rehearse,andgetfeedbackabouthowtousepractices• Strengthenstaffcapacitytointegratenewpracticesandtolearnfromexperience• Ensuringimplementationfidelity• Increasingself-confidenceandenhancingprofessionalnetworks.

Coaching and Mentoring Tools and Resources• ForanevidencereviewproducedbyCentreforEffectiveServicesonwhat works in coaching

and mentoring, clickhere: http://effectiveservices.org/resources/article/coaching-and-mentoring-an-access-

evidence-report

• Foraone-pageinfographicproducedbytheCentreforEffectiveServicesthathighlightsthedifferences between coaching and mentoring, clickhere:

http://effectiveservices.org/resources/article/coaching-and-mentoring-table

• TheNCECwebsitehas resources and advice for Guideline Groups, includingvideosfromstakeholderswhohaveexperienceoftheguidelinedevelopmentprocess:


Coaching is a formal, typically short-term,arrangementbetweenacoachandanindividualfocused on developing work-related skills orbehaviours.

Mentoringisaformalorinformalarrangement,whichtypicallyinvolvesanongoingrelationshipof support for significant transitions inknowledge,thinkingandskills[42]

http://effectiveservices.org/resources/article/coaching-and-mentoring-an-access-evidence-report

http://effectiveservices.org/resources/article/coaching-and-mentoring-an-access-evidence-report

http://effectiveservices.org/resources/article/coaching-and-mentoring-table



NetworksNetworks seek todeepenknowledgeandexpertiseof theirmembersand thegroupasawholeby interacting with each other on an ongoing basis. Networks among groupings of individuals,organisations and/or agencies can take many forms and serve different purposes. Two suchexamplesinclude:

• Knowledge Networks – These lead to accumulation, augmentation and exchange of tacitknowledgeandimprovedskillsrequiredforimplementingspecificinterventions

• Communities of Practice – These aim to solve specific problems by forming self-selected,informalgroupslinkedbysharedexperience,passionsorgoals.

Ongoing Monitoring of OutcomesBased on the planning formonitoring and evaluationconducted during stage 2, implementation teamsshould look to engage in ongoing monitoring ofimplementation outcomes, service outcomes andclientoutcomes.

At this point, Guideline Groups are likely to haveidentifiedoutcomes, KPIs andauditmeasures aspartof guideline development. Using this informationand revisiting documents developed during stages1 and 2, (such as the logic model, implementationplan, enablers and barriers assessment, and themonitoring and evaluation plan) implementationteamscanthereforeseekoutandobtainanyemerginginformationabouttheseoutcomes.

At this stageof implementation,monitoring is formative innature– it providesan indicationofwhether guidelines are functioning andbeing implementedasplanned, an indicationofwhat isworkingwellornotwell,andhowchangescanbemadetoinformimprovement.

Itisalsoimportanttogetanearlysenseofanychangesinserviceoutcomesandclientoutcomes– if the changesarepositive, these canbeused togenerate increasedbuy-in and support frompatients,public,healthcarestaff,managementandpolicy-makers.

Resources to support ongoing monitoring of outcomes• AguidebookproducedbytheNationalResourceCentreintheUSfor‘Strengthening Non-

profits: A Capacity Builder’s Library’ aimstohelpstakeholdersunderstand the concepts, uses and limitations of measuring outcomes.Whilethisresourceisnotdesignedspecificallyforhealthcaresettings,itprovidesusefulinformationforstakeholdersinvolvedinmonitoringguidelines.

To access ‘Strengthening Non-profits: A Capacity Builder’s Library’, click here: http://www.strengtheningnonprofits.org/resources/guidebooks/MeasuringOutcomes.pdf

Benefits of ongoing monitoring of outcomes:

• Increaseaccountability• Identifyanddeliver‘earlywins’• Learnaboutactivitiesand

results• Promotereflection• Identifystrengthsand

weaknesses• Ultimately,informfutureactions

andimprovepractice

http://www.strengtheningnonprofits.org/resources/guidebooks/MeasuringOutcomes.pdf

http://www.strengtheningnonprofits.org/resources/guidebooks/MeasuringOutcomes.pdf


Data-Based Decision MakingGuideline Groups should use processes for collectingandanalysingdifferenttypesofdatatoguidedecisionstowards improvement of clinical guideline processesandoutcomesonanongoingbasis.Thisdatacancomefrommultiple sources, including both standard auditproceduresandspecificeffortstomonitorandevaluateimplementationofclinicalguidelines.

Somequestionsrelatedtoimplementationthatthisdatacanprovideanswerstoinclude:• Aretheprojectedoutcomeslaidoutintheimplementationplanbeingmet?• Aretheindicatorshighlightedintheimplementationplanprovidingusefulinformation?• Areguidelinesbeingimplementedwithfidelity?• Haveanyrisksemerged?

Formeaningfuldecisionsandactionstoariseoutofthismonitoringprocess:üDatarelatingtoguidelinesmustbecollectedüDatamustbemeasured,analysedandreportedaccuratelyüAppropriatereportingandreviewmechanismsmustbeinplacetodeterminewhetherdesired

outcomesarebeingachievedüDecisionsforactionmustbeclearlyinformedandlinkedtothedataandotherevidence.

Data should also be used to support effective feedback loops across multiple system levels.“Without effective feedback loops within and across levels of an organizational system, effective innovations are often changed to fit the existing systems, as opposed to existing systems changing to support effective innovations” [43, p.8] Continuous quality improvement relies on gatheringandassessingfeedbackandcommunicationbetweenvariousstakeholders intheimplementationprocess.Thishelpstoconnectpolicytopracticeandpromotereflectionthatcanleadtobarriersbeing identifiedandaddressedonacontinuousbasis.Therefore,systemsshouldbeput inplacethatensurestakeholderexperiencesarebeing fedbacktoguidelinegroupsanddecision-makersandplayaroleintheirdata-baseddecision-makingprocesses.Itwouldalsobehelpfulforguidelinegroups to consider if, and how, this feedback could be usefully shared throughout the Irishhealthcaresystemandbeyond.

Adapting Implementation Plans for Local SettingsImplementationrequiresmanagementofmany interactingelements in the internalandexternalenvironments. This means that all implementation plans contain a degree of tension betweenmaintainingfidelitytoanintervention’sdesignandneedingtoconsiderandadaptimplementationplanstolocalcontextandconditions.Inreality,duetonaturalvariationinrealworldcontexts,itisalmostimpossibletoapplyanimplementationplanwith100%fidelity.

The Dynamic Sustainability Framework [45] challenges the notion that interventions can bedesigned and tested in a single form that will be applicable across all healthcare settings andpopulationsovertime.Itarguesthatthecharacteristicsofsettingsinwhichinterventionsarebeingdelivered are constantly evolving, including human and capital resources, information systems,organisational culture, climateand structure, andprocesses for trainingand supervisionof staff.Thesuccessofsustaininganinterventionisthereforedependentonitsongoingfitwithinasetting.

Data-Based Decision Making: usingprocessesforcollectingandanalysingdifferenttypesofdatatoguidedecisionstowardsimprovementofprocessesandoutcomesonanongoingbasis.


Ongoing adaptation of implementation plans with a primary focus on fit between guidelinesandpractice settingsmay thereforebe required. Thiswill then lead to ongoing improvement inhealthcareservicedeliveryandoutcomes.Dynamicsustainabilitycanthereforebethoughtofastheprocessofmanagingandsupportingtheevolutionofguidelinesovertimewithinachangingcontext.

Researchershavearguedthattherearetwoseparatecategoriesofimplementationactivities[20]: Core components –theseareessentialand indispensableelementsof the implementation

plan,whichcannotbechangedwithoutunderminingeffectiveness.Allcorecomponentsmustbedeliveredwithtotalfidelity.

Adaptable periphery –theseareelementsoftheimplementationplanwhichmaybetailoredto local settings.Guideline groupsmaybe able tomakeevidence-baseddecisions onhowbesttoadaptelementsoftheirimplementationplantothecontext,withoutunderminingtheintegrityoftheintervention.

Evidence-basedhealthcare/Evidence-basedPractice(EBP)iscomprisedofthreefactors:bestavailableevidence, clinical expertise and patient values. Accordingly, specific clinical recommendationsmay not be appropriate in all cases and it may be necessary to deviate from the guideline. In theseindividualcases,thehealthcarepractitionerrecordsthisdecisioninthepatient’schart.

GuidelineGroupsmayworkwithhealthcareprofessionalsandotherrelevantstakeholdersinlocalsettingstohelpdefinewhichelementsofanimplementationplanmaybeappropriatetoadaptforlocalsettings.Clinicaljudgementinanysuchdecisionsmustbeclearlydocumented.

Best available evidence

Clinicalexpertise

Patientvalues

EBP

Evidence-basedPractice

Stage 4:Full Implementation


Stage 4: Full ImplementationIn stage 4 of implementation, guidelines are fully operational and integrated, used consistently, and embedded in structures. Thismeans that skills and activities are sustained throughout thehealth system,policies andprocedures are fully in place to support changes, andoutcomes areready to be evaluated. Themajority of the specific implementation tasks will be completed atthispoint,meaningthatthe importanttasks forstakeholderswillbetoshowthatguidelinesareworkingandtolookathowprocessesandoutcomescanbecontinuouslyimproved.

Specificactivitiesforimplementingclinicalguidelinesatthisstageinclude:• Evaluatingimplementationoutcomes,serviceoutcomesandclientoutcomes• Engagingincontinuousimprovementcyclestoproducemoreefficientandeffectiveguidelines

EvaluationUpon reaching full implementation, guidelines should be fully operational and integrated intoroutinepractice, i.e.thestandardwayinwhichservicescarryouttheirwork.Thismeansthatallimplementationoutcomes,serviceoutcomesandclientoutcomesarereadytobeevaluated.Thisdiffersfromongoingmonitoringasitislargelysummativeinnature,providingevidenceofwhetherguidelinesarehavingthedesiredimpactonoutcomes.

Appropriatereportingandreviewmechanisms,suchasKPIsandaudit,shouldhavebeenplannedatearlierstagesofimplementation,and,atthispoint,mustbefullyinplacetodeterminewhetherdesiredoutcomesarebeingmet.Havingaccuratedata todemonstratewhether theguideline isbeingimplementedandintendedoutcomesarebeingproducedisofparamountimportance.

Clientoutcomes,serviceoutcomesand implementationoutcomesshouldallbeevaluated.Someservice-focused stakeholders may show most interest in whether guidelines are achieving theresultstheyanticipateanddesire.However, it iscriticalthattimeandresourcesarededicatedtogatheringandanalysingdataonallaspectsof the implementationprocess inorder tomake thenecessaryadjustments tomeet local, contextual conditionsand inorder tounderstandhowthequalityofimplementationaffectsoutcomes[43]

• Returning to theMonitoring and Evaluation of Implementation Planning Tool (Tool 5) to review implementation outcomesmay be useful at this point. This tool was createdbytheCentreforEffectiveServicestohelpGuidelineGroupstothinkaboutandplan for monitoring and evaluation of the implementation process.Whilethistoolshouldinitiallybeusedatanearlystageofguidelinedevelopmenttoensurethatmonitoringandevaluationareembeddedintotheimplementationprocess,itisbeneficialtoreturntothetoolwhenevaluatingimplementationatlaterstagesofimplementation.

To access the Monitoring and Evaluation of Implementation: Planning Tool, click here or see Tool 5.

• The HSE Websiteprovides information, toolsand resources thatencourage theaccuratecollection,analysisandreportingofmonitoring,evaluationandclinicalauditdata:https://www.hse.ie/eng/about/who/qid/measurementquality/

https://www.hse.ie/eng/about/who/qid/measurementquality/

https://www.hse.ie/eng/about/who/qid/measurementquality/


Continuous Improvement CyclesReflectingonemergingevidenceonoutcomesandimplementationprovidesopportunitiestolearnfromexperience and inform future implementation. If guidelines are not being implemented asintendedorarebeingusedasintendedbutnotproducingdesiredoutcomes,improvementcyclescanbeusedtosupportcontinuedimprovementandchange.Thiswillhavethebenefitof:üEnablingGuidelineGroupstoengageboththemselvesandleadershipinusingdatatosupport

implementationcapacity,fidelity,andpatientoutcomes.üEnsuring decisions are data-based, purposeful and planned, rather than opportunistic and

reactionary.

Continuous Improvement CyclesAcommonlyusedmethodisthePlan-Do-Study-ActCycle(PDSA),whichhasfourphases:

1. Plan: use data to identify barriers andchallengesandspecifytheplantoaddressthem, as well as measures to monitorprogress

2. Do: carry out the plan to addresschallenges

3. Study: use measures identified duringthe planning phase to assess and trackprogress

4. Act:makechangestothenextiterationoftheplantoimproveimplementation.

To access the HSE ‘Model for Improvement: Guidance Note on Key Concepts’, which contains useful information on using the PDSA method, click here: https://www.hse.ie/eng/about/who/qid/nationalsafetyprogrammes/pressureulcerszero/model-for-improvement-guidance-document.pdf

The HSE has also published ‘Improving our Services - A users guide to managing change in the Health Service Executive’ https://www.hse.ie/eng/staff/resources/hrstrategiesreports/improving-our-services,-a-guide-to-managing-change-in-the-the-hse---oct-2008.pdf

Itisimportanttorecognisethatbyundertakingcontinuousimprovementcycles,GuidelineGroupsandotherstakeholderswillnotbeabletosolveallchallenges.Implementationisalengthyprocessthatshouldnotberushed,andcontinuedsupportisneededfromleadership,management,orotherkeypartnersinthehealthsystemtoaddressbarrierstoimplementation.Ongoingcommunication,therefore, continues to be necessary at this stage of implementation, so thatmanagement andpolicymakersareequippedwiththeinformationandconfidenceneededtochangethesystemsothatdesiredoutcomescanbeachieved.

Implementation Research: In2018, theCentre for Implementationand ImprovementScience inKings College London published the Implementation Science Research Development (ImpRes) Tool. This tool provides a step-by-step approach to designing implementation research. ImpResencourages research teams todesign robust implementation researchby clearly articulating theimplementationaims that the research seeks toaddress,understanding theactivitiesassociatedwitheachimplementationstage,andselectinganappropriatestudydesign.http://www.kingsimprovementscience.org/ImpRes

https://www.hse.ie/eng/about/who/qid/nationalsafetyprogrammes/pressureulcerszero/model-for-improvement-guidance-document.pdf



https://www.hse.ie/eng/staff/resources/hrstrategiesreports/improving-our-services,-a-guide-to-managing-change-in-the-the-hse---oct-2008.pdf

https://www.hse.ie/eng/staff/resources/hrstrategiesreports/improving-our-services,-a-guide-to-managing-change-in-the-the-hse---oct-2008.pdf

http://http://www.kingsimprovementscience.org/ImpRes


Glossary


GlossaryNote: Many of the terms included in this glossary have been adapted from the National Implementation Research Network (NIRN) online glossary: https://nirn.fpg.unc.edu/learn-implementation/glossary.

Adaptable Periphery: elementsofanimplementationplanwhichmaybetailoredtolocalsettingswithoutunderminingtheintegrityoftheinterventionitself.

Barriers: factorswhichhindertheimplementationprocessandreducetheprobabilityofsuccessfulimplementation.

Capacity: the ability or power to do, understand or absorb something. This can apply to anindividual,ateam,anorganisationorawholesystem.

Clinical/healthcare Audit: aprocesstoimprovepatientcareandoutcomesinvolvingadocumented,structuredandsystematicreviewandevaluation,againstclinicalstandards,orclinicalguidelines,and,wherenecessary,actionstoimproveclinicalcare.

Clinical Guidelines: systematically developed statements, based on a thorough evaluation oftheevidence, toassistpractitionerandserviceusers’decisionsaboutappropriatehealthcare forspecificclinicalcircumstancesacrosstheentireclinicalsystem.

Coaching: aformal,typicallyshort-term,arrangementbetweenacoachandanindividualfocusedondevelopingwork-relatedskillsorbehaviours.

Community:agroupofpeoplelivinginaparticularareaorhavingcharacteristicsincommon(e.g.,city, neighborhood, organisation, service agency, business, professional association); the largersocio-political-culturalcontextinwhichanimplementationprogrammeisintendedtooperate.

Consultation: theactionorprocessofformallydiscussingsomethingwithastakeholder–generallyaskingthestakeholderarelevantquestionandreceivingananswertothatquestion.

Context: the set of circumstances or unique factors that surround a particular implementationeffort.Thiscanrefertoboththewider,systemiccontext,aswellasthespecificsettinginwhichaspecificinterventionwillbeimplemented.

Continuous Improvement Cycles: ongoing useofemergingdataandevidenceonoutcomesandimplementationofguidelines,andusingthatinformationtolearnfromexperience,informfutureimplementationandimproveoutcomes.Progressis,therefore,achievedinanincrementalmannerovertime.

Core Components: essential and indispensable elements of implementation, which cannot bechangedwithoutunderminingtheintervention.Allcorecomponentsmustbedeliveredwithtotalfidelity.

Data-Based Decision Making: usingprocessesforcollectingandanalysingdifferenttypesofdatatoguidedecisionstowardsimprovementprocessesandoutcomesonanongoingbasis.

https://nirn.fpg.unc.edu/learn-implementation/glossary

https://nirn.fpg.unc.edu/learn-implementation/glossary


Diffusion:theprocessbywhichaninnovationiscommunicatedthroughcertainchannelsovertimeamongthemembersofasocialsystem.Thespreadofideasisgenerallyapassiveprocess,followinganunpredictable,unprogrammed,emergentandself-organisingpath.

Dissemination: an active, negotiated and influenced means of distributing information aboutguidelines.

Enablers: factorswhichincreasetheprobabilityofsuccessfulimplementation.

Evaluation: a planned investigation of a project, programme, or policy used to answer specificquestions,oftenrelatedtodesign,implementation,andresults(causeandeffect).

Evidence-Based Interventions:practices,programmes,policies, strategiesorotheractivities thathavebeenempiricallyshownthroughresearchandevaluationprocessestoimproveoutcomestosomedegree.

Fidelity:deliveringanevidence-basedinterventionexactlyassetoutandintendedbythosewhodevelopedit.

Framework: a structure, overview, outline, system or plan consisting of various descriptivecategories, e.g. concepts, constructs or variables, and the relations between them that arepresumed to account for a phenomenon. Frameworks do not provide explanations; they onlydescribeempiricalphenomenabyfittingthemintoasetofcategories.

Implementation: the carrying out of specific planned, intentional activities undertakenwith theaimofmakingevidence-informedpoliciesandpracticesworkbetterforpeople.Itcanbethoughtofasthe‘how’aswellasthe‘what’.

Implementation Plan: alistofkeyactivities, responsibilities,assumptions,resourcerequirements,risksandotherinformationrequiredtoachievethedesiredoutcomesfromguidelines.

Implementation Readiness: theextenttowhichorganisationsandindividualsareboth‘willing’to,and‘capable’of,implementinganyspecificintervention.

Implementation Science:theformalstudyofmethodsandfactorsthatinfluencehowsuccessfullyspecificinterventionsareincorporatedintoservicesettings,leadingtoimprovedoutcomes.

Implementation Team: a group of stakeholders that oversees and attends tomoving guidelinesthrough the stages of implementation. They actively use strategies and supports to facilitateimplementation.

Intervention: anyevidence-informedpolicy, practice, serviceorprogrammebeing implemented,beitachangetoanexistingpolicy,practice,serviceorprogramme,oranewintervention.

Leadership: theactionof leadingagroupofpeople,or theability todo this. Thisdoesnot justapplytoleadingawholeorganisationorsystem–leadershipcantakemultipleformsandcanoccuratanylevelofanorganisationorsystem.

Logic Model: agraphicaldepictionofanintervention’sTheoryofChange,describingconnectionsbetween the intervention’s context, inputs, outputs, and outcomes. It also provides some


information on evidence underpinning the intervention and the monitoring and evaluationprocessesattachedtoit.

Mentoring: aformalor informalarrangementwhichtypically involvesanongoingrelationshipofsupportforsignificanttransitionsinknowledge,thinkingandskills.

Model: adeliberatesimplificationofaphenomenonoraspecificaspectofaphenomenon.Modelsareintendedtobedescriptiveandneednotbecompletelyaccuraterepresentationsofrealitytohavevalue.

Monitoring: the routineandsystematiccollectionof informationagainstaplan. Itmakesuseofexistingdataandinformationaboutinputs,outputs,outcomes,oraboutoutsidefactorsaffectingtheorganisationorproject,toinformimprovement.

Needs Assessment: aprocesswhich clarifies theextent towhichneeds, aswell as barriers andfacilitatorstomeetthoseneeds,areaccuratelyknownandprioritisedbyanorganisationorgroupofpeople.

Outcomes: intendedorunintendedchangesthatoccurasaresultofimplementinginterventions.Thesechangescanoccuratthe levelof individuals,groups,organisationsorpopulation,andcanoccurintheshort-,medium-orlong-term.

Organisational Culture: thenorms,valuesandbeliefs thatexistandgovernbehaviourwithinanorganisation.

Resources: astockorsupplyofmoney,materials,staff,andotherassetsthatcanbedrawnonbyapersonororganisationinordertoeffectivelyimplementguidelines.

Stakeholders: anyone who is affected by or is involved in the development and delivery ofguidelines,includingpatients,public,clinicians,managers,professionalbodies,unions,educators,andpolicy-makers.

Sustainability: guidelinescanbeconsideredtobesustainablewhen notonlyhavetheprocessandoutcomechanged,butthethinkingandattitudesbehindthemarefundamentallyalteredandthesystemssurroundingthemaretransformedaswell. Inotherwords,theinterventionhasbecomeanintegratedormainstreamwayofworkingratherthansomething‘addedon’.

Theory: a set of analytical principles or statements designed to structure our observation,understandingandexplanationoftheworld.A‘goodtheory’providesaclearexplanationofhowandwhyspecificrelationshipsleadtospecificevents.

References


References[1] National Clinical Effectiveness Committee (2015). Standards for Clinical Practice Guidance.

Available from: http://health.gov.ie/wp-content/uploads/2015/11/NCEC-Standards-for-Clinical-Practice-Guidance.-Nov-2015.pdf

[2] Greenhalgh,T.(2018).How to implement evidence-based healthcare. WestSussex,UK:Wiley,4

[3] Kryworuchko, J., Stacey, D., Bai, N., & Graham, I. D. (2009). Twelve years of clinicalpractice guideline development, dissemination and evaluation in Canada (1994 to 2005).Implementation Science, 4(1),pp.49-59.Availablefrom:https://doi.org/10.1186/1748-5908-4-49

[4] Haines, A., Kuruvilla, S.,& Borchert,M. (2004). Bridging the implementation gap betweenknowledgeandactionforhealth.Bulletin of the World Health Organization, 82(10),pp.724-731.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2623035/

[5] Mickan,S.,Burls,A.,&Glasziou,P. (2011).Patternsof ‘leakage’ in theutilisationofclinicalguidelines: a systematic review. Postgraduate Medical Journal. Available from: http://epublications.bond.edu.au/hsm_pubs/302

[6] Gagliardi, A. R., Brouwers, M. C., Palda, V. A., Lemieux-Charles, L., & Grimshaw, J. M.

(2011). How canwe improve guideline use? A conceptual framework of implementability.Implementation Science, 6(1),pp.26-36.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3072935/

[7] Greenhalgh,T.,Howick, J.,&Maskrey,N. (2014).Evidencebasedmedicine:amovement in

crisis? British Medical Journal, 348, g3725. Available from: https://doi.org/10.1136/bmj.g3725

[8] Gagliardi,A.R.,&Brouwers,M.C.(2015).Doguidelinesofferimplementationadvicetotargetusers? A systematic review of guideline applicability. BMJ open, 5(2), e007047. Availablefrom:http://bmjopen.bmj.com/content/5/2/e007047

[9] Gagliardi,A.R.,Marshall,C.,Huckson,S.,James,R.,&Moore,V.(2015).Developingachecklist

forguideline implementationplanning: reviewandsynthesisofguidelinedevelopmentandimplementation advice. Implementation Science, 10(1), p. 19. Available from: https://doi.org/10.1186/s13012-015-0205-5

[10] Liang, L., Abi Safi, J., Gagliardi, A. R., &members of theGuidelines International NetworkImplementationWorkingGroup.(2017).Numberandtypeofguidelineimplementationtoolsvariesbyguideline,clinicalcondition,countryoforigin,andtypeofdeveloperorganization:contentanalysisofguidelines.Implementation Science,12(1),p.136.Availablefrom:http://doi.org/10.1186/s13012-017-0668-7

[11] Michie, S., & Lester, K. (2005). Words matter: increasing the implementation of clinical

guidelines.Quality and Safety in Health Care, 14(5), pp. 367-370. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1744083/pdf/v014p00367.pdf

http://health.gov.ie/wp-content/uploads/2015/11/NCEC-Standards-for-Clinical-Practice-Guidance.-Nov-2015.pdf

http://health.gov.ie/wp-content/uploads/2015/11/NCEC-Standards-for-Clinical-Practice-Guidance.-Nov-2015.pdf

https://doi.org/10.1186/1748-5908-4-49

https://doi.org/10.1186/1748-5908-4-49


http://epublications.bond.edu.au/hsm_pubs/302

http://epublications.bond.edu.au/hsm_pubs/302



https://doi.org/10.1136/bmj.g3725

https://doi.org/10.1136/bmj.g3725

http://bmjopen.bmj.com/content/5/2/e007047

https://doi.org/10.1186/s13012-015-0205-5

https://doi.org/10.1186/s13012-015-0205-5

http://doi.org/10.1186/s13012-017-0668-7

http://doi.org/10.1186/s13012-017-0668-7

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1744083/pdf/v014p00367.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1744083/pdf/v014p00367.pdf


[12] National Clinical Effectiveness Committee (2015). National Clinical Guideline Proposal Template.Available from:http://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/ncec-processes-and-templates/

[13] BrouwersM.,KhoM.E.,BrowmanG.P.,CluzeauF.,FederG.,FerversB.,HannaS.,Makarski

J., on behalf of the AGREE Next Steps Consortium. (2010). AGREE II: Advancing guidelinedevelopment,reportingandevaluationinhealthcare.Canadian Medical Association Journal, 182,pp.839-842.Availablefrom:http://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf

[14] Burke, K., Morris, K. & McGarrigle, L. (2012). An introductory guide to implementation.

Available from: http://effectiveservices.org/downloads/Guide_to_implementation_concepts_and_frameworks_Final.pdf

[15] Fixsen, D.L., & Blasé, K.A. (2009). NIRN Implementation Brief Number 1 Available from:http://files.eric.ed.gov/fulltext/ED507422.pdf

[16] Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion ofinnovations inserviceorganizations:systematicreviewandrecommendations.The Milbank Quarterly, 82(4), pp. 581-629. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690184/

[17] Tabak, R. G., Khoong, E. C., Chambers, D. A., & Brownson, R. C. (2012). Bridging research

and practice:models for dissemination and implementation research.American Journal of Preventive Medicine, 43(3),pp.337-350.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3592983/

[18] Powell,B.(2017).Global Implementation Conference Academy Workshop(June2017).

[19] Nilsen, P. (2015). Making sense of implementation theories, models and frameworks.Implementation Science, 10(1), p. 53. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4406164/

[20] Damschroder,L.J.,Aron,D.C.,Keith,R.E.,Kirsh,S.R.,Alexander,J.A.,&Lowery,J.C.(2009).Fostering implementationofhealth services researchfindings intopractice: a consolidatedframework foradvancing implementationscience. Implementation Science, 4(1),pp.50-64.Availablefrom:https://doi.org/10.1186/1748-5908-4-50

[21] Rycroft-Malone, J. (2004). The PARIHS framework — A framework for guiding the

implementation of evidence-based practice. Journal of Nursing Care Quality, 19(4), pp.297-304. Available from: http://www.effectiveservices.org/downloads/The_PARIHS_Framework-A_framework_for_guiding_the_implementation_of_evidence_based_practice.pdf

[22] Fixsen,D.L.,Naoom,S.F.,Blasé,K.A.,&Friedman,R.M.(2005).Implementationresearch:

a synthesis of the literature.Available from:http://nirn.fpg.unc.edu/sites/nirn.fpg.unc.edu/files/resources/NIRN-MonographFull-01-2005.pdf



http://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf

http://www.agreetrust.org/wp-content/uploads/2013/10/AGREE-II-Users-Manual-and-23-item-Instrument_2009_UPDATE_2013.pdf

http://effectiveservices.org/downloads/Guide_to_implementation_concepts_and_frameworks_Final.pdf

http://effectiveservices.org/downloads/Guide_to_implementation_concepts_and_frameworks_Final.pdf

http://files.eric.ed.gov/fulltext/ED507422.pdf







https://doi.org/10.1186/1748-5908-4-50

http://www.effectiveservices.org/downloads/The_PARIHS_Framework-A_framework_for_guiding_the_implementation_of_evidence_based_practice.pdf



http://nirn.fpg.unc.edu/sites/nirn.fpg.unc.edu/files/resources/NIRN-MonographFull-01-2005.pdf

http://nirn.fpg.unc.edu/sites/nirn.fpg.unc.edu/files/resources/NIRN-MonographFull-01-2005.pdf


[23] Powell,B.J.,Proctor,E.K.,Smith,J.L.,Kirchner,J.E.,Damschroder,L.J.,Chinman,M.J., ...&Waltz, T. J. (2015). A refined compilation of implementation strategies: results from theExpertRecommendationsfor ImplementingChange(ERIC)project. Implementation Science, 10(1),p.21.Availablefrom:https://doi.org/10.1186/s13012-015-0209-1

[24] Baker,R.,Camosso-Stefinovic,J.,Gillies,C.,Shaw,E.J.,Cheater,F.,Flottorp,S.,&Robertson,

N. (2010). Tailored interventions to overcome identified barriers to change: effects onprofessional practice and health care outcomes. Cochrane Database Systematic Review (3): CD005470. Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005470.pub2/full

[25] Centre for Effective Services (2017). Stakeholder Engagement Tool. Available from: http://

effectiveservices.org/resources/article/stakeholder-engagement-tool [26] National Clinical Effectiveness Committee (2018). Public Involvement Framework. Available

from:http://health.gov.ie/national-patient-safety-office/ncec/public-involvement-framework/

[27] Kochevar, L. K., & Yano, E. M. (2006). Understanding health care organization needs andcontext.Journal of general internal medicine,21(S2),pp.25-29.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2557132/

[28] Proctor,E.,Silmere,H.,Raghvan,R.,Hovmand,P.,Aarons,G.,Bunger,A.,Griffey,R.,Hensley,M. (2010). Outcomes for implementation research: Conceptual distinctions, measurementchallenges,andresearchagenda.Administration and Policy in Mental Health, 38(2),pp.65-76.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068522/

[29] Moore, J.E., Mascarenhas, A., Marquez, C., Almaawiy, U., Waihin Chan, D’Souza, J, Liu, B.,

Straus, S.E., & the MOVE ON Team (2014). Mapping barriers and intervention activities to behaviour change theory for Mobilization of Vulnerable Elders in Ontario (MOVE ON), a multi-site implementation intervention in acute care hospitals. Implementation Science, 9(1), p. 160. Availablefrom: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4225038/

[30] Shea,C.M., Jacobs,S.R.,Esserman,D.A.,Bruce,K.,&Weiner,B. J. (2014).Organizationalreadiness for implementing change: A psychometric assessment of a new measure. Implementation Science, 9(1),7.Availablefrom:https://doi.org/10.1186/1748-5908-9-7

[31] Weiner,B.J.,Lewis,M.A.,&Linnan,L.A.(2009).Usingorganizationtheorytounderstandthedeterminants of effective implementation of worksite health promotion programs.Health Education and Research, 24(2),pp.292-305.Availablefrom:https://academic.oup.com/her/article/24/2/292/572832

[32] Dymnicki, A., Wandersman, A., Osher, D., Grigorescu, V., Huang, L. (2014). Office of the

Assistant Secretary for Planning and Evaluation (ASPE) Issue Brief Available from: https://aspe.hhs.gov/system/files/pdf/77076/ib_Readiness.pdf

[33] Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model ofevidence-basedpracticeimplementationinpublicservicesectors.Administration and Policy in Mental Health and Mental Health Services Research, 38(1), pp. 4-23. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025110/

https://doi.org/10.1186/s13012-015-0209-1

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005470.pub2/full

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD005470.pub2/full








https://doi.org/10.1186/1748-5908-9-7

https://academic.oup.com/her/article/24/2/292/572832

https://academic.oup.com/her/article/24/2/292/572832

https://aspe.hhs.gov/system/files/pdf/77076/ib_Readiness.pdf

https://aspe.hhs.gov/system/files/pdf/77076/ib_Readiness.pdf



[34] West,M.,Eckert,R.,Steward,K.,&Pasmore,B.(2014).Developingcollectiveleadershipforhealth care. London:TheKing’s Fund.Available from: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/developing-collective-leadership-kingsfund-may14.pdf

[35] Gifford, W. A., Davies, B., Edwards, N., & Graham, I. D. (2006). Leadership strategies to

influence the use of clinical practice guidelines. Canadian Journal of Nursing Leadership, 19(4),pp.72-88.Availablefrom:https://www.ncbi.nlm.nih.gov/pubmed/17265675

[36] Health Information and Quality Authority (2012). National Standards for Safer Better

Healthcare. Available from: https://www.hiqa.ie/system/files/Safer-Better-Healthcare-Standards.pdf

[37] HealthServiceExecutive(2017).A Practical Guide to Clinical Audit. Available from:https://www.hse.ie/eng/about/Who/QID/MeasurementQuality/Clinical-Audit/practticalguideclaudit.html

[38] NHS Institute for Innovation and Improvement (2005). Sustainability: Model and Guide. Availablefrom:https://improvement.nhs.uk/resources/Sustainability-model-and-guide/

[39] Whelan,J.,Love,P.,Pettman,T.,Doyle,J.,Booth,S.,Smith,E.,&Waters,E.(2014).Predicting

sustainability of intervention effects in public health evidence: identifying key elements toprovide guidance. Journal of Public Health, 36(2), pp. 347-351. Available from: https://academic.oup.com/jpubhealth/article/36/2/347/2901777

[40] Joyce,B.R.,&Showers,B.(2002).Studentachievementthroughstaffdevelopment(3rded.).

Alexandria,VA:AssociationforSupervision&CurriculumDeve(ASCD).

[41] Aarons, G. A., Sommerfeld, D. H., Hecht, D. B., Silovsky, J. F., & Chaffin,M. J. (2009). Theimpactofevidence-basedpracticeimplementationandfidelitymonitoringonstaffturnover:evidenceforaprotectiveeffect.Journal of Consulting and Clinical Psychology, 77(2),p.270.Availablefrom:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742697/

[42] Morgan, M. and Rochford, S. (2017) Coaching and Mentoring for Frontline Practitioners.

Centre for Effective Services, Dublin. Available from: http://www.effectiveservices.org/downloads/CoachMentor_LitReview_Final_14.03.17.pdf

[43] Metz,A.,Naoom,S.F.Halle,T.,&Bartley,L.(2015).Anintegratedstage-basedframeworkfor

implementationofearlychildhoodprogramsandsystems.OPREResearchBrief48.Availablefrom:http://www.acf.hhs.gov/sites/default/files/opre/es_cceepra_stage_based_framework_brief_508.pdf

[44] Barwick, M.A. (2011). Checklist to Assess Organizational Readiness (CARI) for EIP Implementation. Available from: http://www.effectiveservices.org/resources/article/checklist-to-assess-organisation-readiness

[45] Chambers,D.,A.,Glasgow,R.E.,&Stange,K.C.(2013).Thedynamicsustainabilityframework:Addressing the paradox of sustainment amid ongoing change. Implementation Science, 8(117),1-11.Availablefrom:https://doi.org/10.1186/1748-5908-8-117

https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/developing-collective-leadership-kingsfund-may14.pdf



https://www.ncbi.nlm.nih.gov/pubmed/17265675

https://www.hiqa.ie/system/files/Safer-Better-Healthcare-Standards.pdf

https://www.hiqa.ie/system/files/Safer-Better-Healthcare-Standards.pdf

https://www.hse.ie/eng/about/Who/QID/MeasurementQuality/Clinical-Audit/practticalguideclaudit.html




https://academic.oup.com/jpubhealth/article/36/2/347/2901777

https://academic.oup.com/jpubhealth/article/36/2/347/2901777


http://www.effectiveservices.org/downloads/CoachMentor_LitReview_Final_14.03.17.pdf

http://www.effectiveservices.org/downloads/CoachMentor_LitReview_Final_14.03.17.pdf

http://www.acf.hhs.gov/sites/default/files/opre/es_cceepra_stage_based_framework_brief_508.pdf

http://www.acf.hhs.gov/sites/default/files/opre/es_cceepra_stage_based_framework_brief_508.pdf



https://doi.org/10.1186/1748-5908-8-117


Additional Implementation Websites and Resources


Additional Implementation Websites and Resources

CentreforEffectiveServicesimplementationresourceshttp://www.effectiveservices.org/resources/tag/implementation

Disseminationandimplementationmodelsinhealthresearchandpractice–interactivewebsitehttp://www.dissemination-implementation.org/

EuropeanImplementationCollaborative(EIC)implementationresourceshttp://www.implementation.eu/resources

GuidelinesInternationalNetwork(GIN)http://www.g-i-n.net/home

KingsCollegeLondon–CentreforImplementationSciencehttps://www.kcl.ac.uk/ioppn/depts/hspr/research/cis/index.aspx

NationalImplementationResearchNetwork(NIRN)(US)resourcehubhttp://implementation.fpg.unc.edu/

National Patient Safety Office Learning Zone (including videos and slides from the Centre forEffectiveServices’2-DayIntroductiontoImplementationScienceTraining)https://health.gov.ie/national-patient-safety-office/ncec/resources-and-learning/

ScottishIntercollegiateGuidelinesNetwork(SIGN)http://www.sign.ac.uk/

TrinityCollegeDublinPostgraduateCertificateinImplementationSciencehttps://www.tcd.ie/medicine/public_health_primary_care/postgraduate/cis/index.php

UniversityCollegeLondon,CentreforBehaviourChangehttp://www.ucl.ac.uk/behaviour-change

Bauer,M.S.,Damschroder,L.,Hagerdorn,H.,Smith,J.,&Kilbourne,A.M.(2015).Anintroductionto implementation science for thenon-specialist.BMC Psychology, 3,pp.32-43.Retrieved from:https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-015-0089-9

Ogden, T., & Fixsen, D. L. (2014). Implementation science: A brief overview and a lookahead. Zeitschrift fȕr Psychologie, 222, 4-11. Retrieved from: https://www.researchgate.net/publication/259962369_Implementation_Science_A_Brief_Overview_and_a_Look_Ahead

Peters, D. H., Tran, N.T., Adam, T. (2013). Implementation research in health: A practical guide.Geneva: World Health Organization. Retrieved from: http://who.int/alliance-hpsr/alliancehpsr_irpguide.pdf

Rabin,B.A.,Brownson,R.C.,Haire-Joshu,D.,Kreuter,M.W.,&Weaver,N.L.(2008).Aglossaryfordisseminationand implementationresearch inhealth.Journal of Public Health Management and Practice, 14(2),117-123.Retrievedfrom:http://chipcontent.chip.uconn.edu/chipweb/documents/DI/Rabin_etal_2008.pdf

http://www.effectiveservices.org/resources/tag/implementation

http://www.dissemination-implementation.org/

http://www.implementation.eu/resources

http://www.g-i-n.net/home

https://www.kcl.ac.uk/ioppn/depts/hspr/research/cis/index.aspx

http://implementation.fpg.unc.edu/


https://www.tcd.ie/medicine/public_health_primary_care/postgraduate/cis/index.php

http://www.ucl.ac.uk/behaviour-change

https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-015-0089-9

https://www.researchgate.net/publication/259962369_Implementation_Science_A_Brief_Overview_and_a_Look_Ahead

https://www.researchgate.net/publication/259962369_Implementation_Science_A_Brief_Overview_and_a_Look_Ahead

http://who.int/alliance-hpsr/alliancehpsr_irpguide.pdf

http://who.int/alliance-hpsr/alliancehpsr_irpguide.pdf

http://chipcontent.chip.uconn.edu/chipweb/documents/DI/Rabin_etal_2008.pdf

http://chipcontent.chip.uconn.edu/chipweb/documents/DI/Rabin_etal_2008.pdf


Appendix A – Summary of Implementation Science Frameworks

Tool 1. The Hexagon Tool

Tool 2. Logic Model

Tool 3. Implementation Enablers and Barriers: Assessment Tool

Tool 4. Implementation Planning Tool

Tool 5. Monitoring and Evaluating Implementation: Planning Tool

CopiesoftheindividualtoolsarealsoavailabletodownloadfromtheNCECwebsitehttps://health.gov.ie/national-patient-safety-office/ncec/



Appendix A – Summary of Implementation Science Frameworks

1. Active Implementation FrameworkDescriptionAssociated with the National Implementation Research Network (NIRN) in the US, the ActiveImplementationFrameworkemergedfromasynthesisoftheimplementationliterature.1

Key FeaturesFramedaroundfour‘keyingredients’foractiveimplementation:

1. It takes time–stagesofimplementation

2. It takes a village–implementationteams

3. It takes support–competency,organisationalandleadershipsupports

4. It takes communication–feedbackloops

LinkActiveImplementationHub:http://implementation.fpg.unc.edu/

2. Consolidated Framework for Implementation Research (CFIR)

DescriptionThis framework combines common elements from multiple implementation theories, offeringconsistent terminology. It places anemphasis on adapting interventions tofit the settingwherethey will be implemented, and continuous improvement of implementation throughout theprocess.2

Key FeaturesFivemajordomains:

1. Interventioncharacteristics2. Outersetting3. Innersetting4. Individualcharacteristicsoftheimplementers5. Theprocessofimplementation

Eachisbrokendownintocomponentparts,enablingdetailedanalysis.

Linkhttp://www.cfirguide.org/

http://implementation.fpg.unc.edu/

http://www.cfirguide.org/


3. Promoting Action on Implementation Research in Health (PARiHS)DescriptionThisframeworkisdesignedtoaidinimplementingresearchintopractice.Itfocusesonorganisationalchange, rather than individual change, noting that organisations with transformational leaders,elementsoflearningorganisations,andevaluationmechanismshavethemostsuccess.3

Key FeaturesThreefactorsdetermineresearchuse:

• RobustEvidence–research;clinicalexperience;patientpreferences;localinformation• ReceptiveContext–culture;leadership;evaluation• FacilitationofChange–respect;credibility;empathy;clarity;flexible;consistent

Allthreeareequallyimportant,meaningthatthecontextinwhichevidenceisbeingused,andthewayitisintroduced,hasasmuchtodowithimplementationasthequalityoftheevidence.

LinkSummaryoftheframework:http://www.nccmt.ca/resources/search/85

4. RE-AIM (Reach Effectiveness Adoption Implementation Maintenance)DescriptionThisisacomprehensiveframeworkdesignedforevaluationofpublichealth,healthpromotionandcommunity-basedinterventions.Itallowsforpolicy,environmentalandindividuallevelcomponentstobeevaluatedwithmeasuressuitedtotheirsetting,goalsandpurpose.

Key FeaturesTheframeworkismadeoffivemajorelementsforevaluatingimplementation:

• Reach• Effectiveness• Adoption• Implementation• Maintenance

Linkhttp://re-aim.org/

http://www.nccmt.ca/resources/search/85

http://re-aim.org/


5. Normalisation Process TheoryDescriptionThis theory and its associated tools primarily target researchers who are designing complexinterventions.Ratherthanfocusingontheprocessforimplementation,asmanyotherframeworksdo, it aims to ensure that there is good potential for implementation due to the design of theintervention.Thetoolsencouragethecreationof interventionswhicharecapableofwidespreadimplementationandcaneasilybenormalisedintoroutinepractice.4

Key FeaturesThereisadynamicrelationshipbetweenfourmajorelements:

• Coherence–meaningandsense-makingbyparticipants• Cognitive Participation–commitmentandengagementbyparticipants• Collective Action–theworkparticipantsdotomaketheinterventionfunction• Reflexive Monitoring–participantsappraisetheintervention

LinkToolsavailableat:http://www.normalizationprocess.org/

6. COM-BDescriptionA model of behaviour changeusedtoidentify whatisneededtoattain thedesiredbehaviourat individual,practitioneror organisationallevel.

Key FeaturesThismodelpositsthatbehaviouroccursasan interactionbetweenthreeconditions:

• Capability–Psychologicalorphysicalability toenactbehaviour

• Motivation–Reflectiveandautomatic mechanismsthatactivateorinhibitbehaviour

• Opportunity–Physicalandsocial environmentthatenablesthebehaviour

The Behaviour Change Wheel5 shows how these conditions may be affected by certaininterventions,andhowpolicydecisionsmayimpactontheseinterventions.Thisallowsyouto:

• Identifybehavioursthatneedtochange• Understandthesebehaviours• Considerarangeofeffectivestrategies

Linkhttp://www.behaviourchangewheel.com/

http://www.normalizationprocess.org/

http://www.behaviourchangewheel.com/


7. IHI Framework for Leadership for ImprovementDescriptionDevelopedbytheInstituteforHealthcareImprovement(IHI),thisframeworkorganisesleadershipprocessesthatfocustheorganisationandseniorleadersonimprovement6

Key FeaturesPrimaryuses:

• Providesanorganisingstructuretounderstandhowtheactivitiesofhealthcareleaderscontributestotransformationandimprovement

• Assessmentandimprovementoforganisations• Guidethedesignofleadershipdevelopmentprogrammes

IHI Framework for Leadership for Improvement

Link http://www.ihi.org/resources/Pages/Tools/IHIFrameworkforLeadershipforImprovement.aspx

References[1] Fixsen, D.L., Naoom, S.F., Blasé, K.A., Friedman, R.M., Wallace, F. (2005). Implementation

Research:Asynthesisoftheliterature(FMHI#231).Tampa,FL:UniversityofSouthFlorida,LouisdelaParteFloridaMentalHealthInstitute,TheNationalImplementationResearchNetwork.

[2] Damschroder,L.J.,Aron,D.C.,Keith,R.E.,Kirsh,S.R.,Alexander,J.A.,&Lowery,J.C.(2009).Fostering implementation of health services research findings into practice: A consolidatedframeworkforadvancingimplementationscience.Implementation Science, 4(1),p.50.

[3] Rycroft-Malone,J.(2004).ThePARiHSFramework–Aframeworkforguidingtheimplementationofevidence-basedpractice.Journal of Nursing Care Quality, 19(4),pp.297-304.

[4] Murray, E., Treweek, S., Pope, C.,MacFarlane, A., Ballini, L., Dowrick, C., Finch, T., Kennedy,A.,Mair,F.,O’Donnell,C.,NioOng,B.,Rapley,T.,Rogers,A.,&May,C.(2010).Normalisationprocess theory: A framework for developing, evaluating and implementing complexinterventions.BMC Medicine, 8(63),pp.1-11.

[5] Michie, S., van Stralan M., West R. (2011). The behaviour change wheel: A new method forcharacterisinganddesigningbehaviourchangeinterventions.Implementation Science, 6(1),p.42.

[6] Reinertsen, J.L., Bisognano,M., & Pugh,M.D. (2008). Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (SecondEdition). IHI InnovationSerieswhitepaper.Cambridge,MA:InstituteforHealthcareImprovement.Availableonwww.IHI.org

3. Bulld Will•PlanforImprovement•SetAims/AllocateResources•MeasureSystemPerformance•ProvideEncouragement•MakeFinancialLinkages•LearnSubjectMatter•WorkontheLargerSystem

4. Generate Ideas•ReadandScanWidely,LearnfromOtherIndustriesandDisciplines

•BenchmarktoFindIdeas•ListentoCustomers•InvestInResearchandDevelopment

•ManageKnowledge•UnderstandOrganizationasaSystem

5. Execute Change•UseModelforImprovementforDesignandRedesign

•ReviewandGuldeKeyInitiatives

•SpreadIdeas•CommunicateResults•SustainImprovedLevelsofPerformance

1. Set Direction: Mission, Vision, and StrategyMake the status quo uncomfortable Make the future attractive

2. Establish the Foundation•ReframeOperatingValues•BuildImprovementCapability

•PreparePersonally•ChooseandAligntheSenior

Team

•BuildRelationships•DevelopFutureLeaders

²PUSH ²PULL

http://www.ihi.org/resources/Pages/Tools/IHIFrameworkforLeadershipforImprovement.aspx

www.IHI.org


Tool 1 – The Hexagon Tool

•Identifytheneedsofserviceusersandcommunitiesthroughconsultation,researchandanalysisofdata

•Assesswhatinterventionsarelikelytoaddresstheidentifiedneeds

•Identifyifthesettinghasthenecessarycapacitytoabsorbandsustaintheintervention(e.g.staffwithrequiredqualifications,leadership,finance,andstructures)

•Assessthelevelofbuy-infortheintervention

•Examineiftheinterventionisclearlydefinedandhasbeenusedinmultiplesettings

•Establishwhethertheexpertiseintheinterventionisavailableandaccessible

•Assessiftheinterventionfitswithcurrentinitiatives,structuresandvalues

•Examineitsfitwithlocalandnationalpoliciesandpriorities

•Identifynecessaryresources:– Technology/datasystems– Staffing– Training,coachingand

supervision– Physicalinfrastructure– Administrativeandsystem

supports•Assesswhatadditionalresourcesarerequiredforimplementation

•Consultandassesstheevidenceinrelationtotheinterventiononwhatworks,inwhatcontexts,andwithwhom

•Assesstheevidenceonimplementationandcost

Need

Evidence

Intervention Readiness

Capacity to Implement

Resource Availability

Fit

Intervention:

TheHexagonToolcanbeusedasaplanningtooltoevaluatepotentialevidence-basedguidelinerecommendationsduringtheExploration Stageofimplementation.

Pleaseratethefollowingaspectsofimplementationreadinessin accordance with your guideline(ticktheappropriatebox):

High Med Low

Need

Fit

Resource Availability

Evidence

Intervention Readiness

Capacity to Implement

Adapted from the National Implementation Research Network (NIRN) Hexagon Tool by theCentre for Effective Services, with permission from NIRN. Original version available at: https://implementation.fpg.unc.edu/sites/implementation.fpg.unc.edu/files/resources/NIRN-HexagonDiscussionandAnalysisTool2018_FINAL.pdf

ThistoolisavailableonNCECwebsite:https://health.gov.ie/national-patient-safety-office/ncec/

https://implementation.fpg.unc.edu/sites/implementation.fpg.unc.edu/files/resources/NIRN-HexagonDiscussionandAnalysisTool2018_FINAL.pdf





Tool 2 – Logic Model

Monitoring and Evaluation

Situation Analysis Inputs Activities/

OutputsShort-term Outcomes

Evidence

Long-term Outcomes

Thebasicoutlineofalogicmodelisshownaboveandablank,editableversionisprovidedonthefollowingpage.ItshouldbecompletedbyGuidelineGroupsinthefollowingsequenceofsteps:

1. SituationAnalysis2. Short-TermandLong-TermOutcomes3. Activities/Outputs4. Inputs5. MonitoringandEvaluation6. EvidenceunderpinningallaspectsoftheLogicModel

Guidance for completing each specific section of the logicmodel is provided in the text of theImplementationGuide.ThefollowingtipsandhintsshouldalsohelpGuidelineGroupstofill inalogicmodelfortheirguideline:

• Whilealogicmodelshouldbereadfromlefttorightoncecompleted,itismostlydeveloped from right to left, beginning with outcomes (after completing the situation analysis) andworkingbackthroughactivities/outputsandinputs.

• Thoughitisoftendifficulttobeprecise,being as concrete as possible,intermsoffiguresandtargetslisted,isbetterforplanning,implementation,accountabilityandevaluationpurposes.

• Outcomes inserted into a logic model can be clearly grouped bywhethertheyarerelatedtoimplementationoutcomes,serviceoutcomesorclientoutcomes

• List any anticipated inputs and discuss any issues arising. If you are intending to workin partnership, for example, what would you need to consider in terms of planning orimplementation?

• Workalreadydoneonthe Hexagon Tool and outcomes can form the basis for development of a logic model




Mon

itorin

g an

d Ev

alua

tion

Situ

ation

Ana

lysi

sIn

puts

Activ

ities

/Out

puts

(wha

t we

do)

Shor

t-ter

m O

utco

mes

(res

ults

/cha

nges

)

Implem

entatio

nOutcomes

ServiceOutcomes

ClientOutcomes

Evid

ence

Long

-term

Out

com

es(r

esul

ts/c

hang

es)

Implem

entatio

nOutcomes

ServiceOutcomes

ClientOutcomes

Logi

c M

odel

Tem

plat

e –

Nati

onal

Clin

ical

Gui

delin

es


Tool 3 – Implementation Enablers and Barriers: Assessment Tool

Introduction to the Implementation Enablers and Barriers Assessment ToolA wide range of factors influence whether implementation is successful. Assessing andunderstanding these factors can help to identify barriers and facilitators to change and informimplementationplanning.Thisassessmenttoolprovidesanoverviewofkeyfactorsthatinfluenceimplementationandassistspeopleinassessingthese.Italsohelpswithidentifyingopportunitiestostrengthenimplementation.

The factors influencing implementation are organised around the four areas presented in thegraphic:

Thistoolbuildsontwotheoreticalframeworks:• The Consolidated Framework for Implementation Research(CFIR)(Damschroderet al.,2009)[1]

and• The Behaviour Change Wheel(Michieet al.,2011)[2]

1. Intervention Characteristics• Sourceofintervention• Evidencestrengthandquality• Relativeadvantage• Trialability• Complexity• Designquality• Cost

2. Outer setting• Patientneedsandresources• Cosmopolitanism(external

networksandrelationships)• Peerpressure• Externalpoliciesandincentives

3. Inner Setting• Structuralcharacteristics• Networksandcommunications• Culture• Implementationclimate• Readinessforimplementation

4. Characteristics of Individuals• Capacity-physicaland

psychological• Motivation

Implementation Influences (enablers

& barriers)




Thistoolcanbecompletedforindividual recommendationswithinNationalClinicalGuidelines,orforaguideline/project as a whole. Itcanalsobeusedtoassessenablersandbarriersatvarious levels,suchasatanationallevelorinaparticularhealthcaresetting.

In completing this tool, you should focus on factors that aremost relevant and salient to yourguideline and its stage of implementation. For example, youmaywish to focus on factors thatwillbemostfruitfultoaddress.Werecommendthatyouchoosebetweenfivetosevenfactorstoassessandatleastonefactorfromeachofthefourareas.Usethetablebelowtoselectthefactorsyouarefocusingonbyticking(ü)intherelevantboxes

FACTORS INFLUENCING IMPLEMENTATION Tick (ü)

1. Intervention characteristics

a) Interventionsource

b) Evidencestrengthandquality

c) Relativeadvantage

d) Trialability

e) Complexity

f) Designquality

g) Cost

2. Outer setting

a) Patientneedsandresources

b) Cosmopolitanism(networksandrelationships)

c) Peerpressure

d) Externalpoliciesandincentives

3. Inner Setting

a) Structuralcharacteristics

b) Networksandcommunications

c) Culture

d) Implementationclimate

e) ReadinessforImplementation

4. Characteristics of Individuals

a) Capacity-physicalandpsychological

b) Motivation

77Implementation Guide and Toolkit for National Clinical Guidelines1.

INTE

RVEN

TIO

N C

HARA

CTER

ISTI

CS

An in

terv

entio

n is

defi

ned

as a

ny c

hang

e to

pol

icy

or p

racti

ce. I

t cou

ld re

fer t

o a

Nati

onal

Clin

ical

Gui

delin

e an

d/or

indi

vidu

al

reco

mm

enda

tions

with

in th

em.

A ra

nge

of in

terv

entio

n att

ribut

es c

an in

fluen

ce th

e su

cces

s of i

mpl

emen

tatio

n.

A) IN

TERV

ENTI

ON

SO

URC

ETh

e pe

rcei

ved

legi

timac

y an

d cr

edib

ility

of t

he s

ourc

e (e

.g. a

cade

mic

col

lege

, HSE

clin

ical

pro

gram

me

or a

dvoc

acy

grou

p) o

f the

inte

rven

tion,

in

clud

ing

whe

ther

the

inte

rven

tion

is de

velo

ped

exte

rnal

ly o

r int

erna

lly.

If th

is is

an

exis

ting

inte

rven

tion,

who

dev

elop

ed

it; w

ho is

the

spon

sor;

who

is re

spon

sibl

e fo

r up

date

and

impl

emen

tatio

n?

To w

hat e

xten

t is t

he

inte

rven

tion

cons

ider

ed to

be

app

ropr

iate

? (ti

ck re

spon

se)

□High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g thi

s? (I

f uns

ure,

w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

78 Implementation Guide and Toolkit for National Clinical GuidelinesB)

EVI

DEN

CE S

TREN

GTH

AND

QUA

LITY

The

qual

ity a

nd v

alid

ity o

f the

evi

denc

e in

dica

ting

that

the

inte

rven

tion

will

hav

e th

e de

sired

out

com

es.

Wha

t sup

porti

ng e

vide

nce

show

s the

inte

rven

tion

will

wor

k?

How

do

stak

ehol

ders

pe

rcei

ve th

e st

reng

th o

f th

e ev

iden

ce b

ase

for t

he

inte

rven

tion?

(ti

ck re

spon

se)

□High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g thi

s? (I

f uns

ure,

w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

C) R

ELAT

IVE

ADVA

NTA

GE

The

adva

ntag

e of

impl

emen

ting

the

inte

rven

tion

vers

us a

n al

tern

ative

solu

tion.

Wha

t adv

anta

ges d

oes t

he in

terv

entio

n ha

ve

com

pare

d to

alte

rnati

ves?

To

wha

t ext

ent i

s the

in

terv

entio

n co

nsid

ered

to

be

bett

er th

an c

urre

nt

and/

or a

ltern

ative

pr

actic

es?

(tick

resp

onse

) □

High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g thi

s? (I

f uns

ure,

w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

79Implementation Guide and Toolkit for National Clinical GuidelinesD)

TRI

ALAB

ILIT

YTh

e ab

ility

to te

st th

e in

terv

entio

n on

a sm

all s

cale

in a

setti

ng, a

nd to

be

able

to re

vers

e co

urse

(und

o im

plem

enta

tion)

if w

arra

nted

.

Has t

he in

terv

entio

n be

en p

ilote

d or

are

ther

e pl

ans t

o pi

lot t

he in

terv

entio

n pr

ior t

o fu

ll-sc

ale

impl

emen

tatio

n?

To w

hat e

xten

t is i

t po

ssib

le to

tria

l/pi

lot t

he

inte

rven

tion

prio

r to

full-

scal

e im

plem

enta

tion?

(tick

resp

onse

) □

High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g thi

s? (I

f uns

ure,

w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

E) C

OM

PLEX

ITY

The

com

plex

ity o

f th

e in

terv

entio

n, r

eflec

ted

by d

urati

on, s

cope

, rad

ical

ness

, disr

uptiv

enes

s, c

entr

ality

, and

intr

icac

y an

d nu

mbe

r of

ste

ps

requ

ired

to im

plem

ent.

How

com

plic

ated

is th

e in

terv

entio

n?W

hat i

s the

leve

l of c

hang

e re

quire

d to

impl

emen

t the

in

terv

entio

n an

d re

plac

e ex

istin

g pr

actic

es?

(tick

resp

onse

) □

High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g thi

s? (I

f uns

ure,

w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

80 Implementation Guide and Toolkit for National Clinical GuidelinesF)

DES

IGN

QUA

LITY

AN

D PA

CKAG

ING

Qua

lity

of th

e m

ater

ials

and

supp

orts

ava

ilabl

e to

hel

p im

plem

ent a

nd u

se th

e in

terv

entio

n.

Wha

t res

ourc

es, t

ools

and

supp

orts

are

ava

ilabl

e to

hel

p im

plem

ent a

nd u

se th

e in

terv

entio

n?

How

do

you

rate

the

qual

ity o

f the

reso

urce

s de

velo

ped

to su

ppor

t im

plem

enta

tion

of th

e in

terv

entio

n?(ti

ck re

spon

se)

□High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g thi

s? (I

f uns

ure,

w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

G) C

OST

Cost

s of t

he in

terv

entio

n an

d co

sts a

ssoc

iate

d w

ith im

plem

entin

g th

e in

terv

entio

n in

clud

ing

inve

stm

ent,

supp

ly, a

nd o

ppor

tuni

ty c

osts

.

Wha

t cat

egor

ies o

f cos

ts w

ill b

e in

curr

ed in

im

plem

entin

g th

e in

terv

entio

n? (e

.g. s

taffi

ng,

equi

pmen

t, IT

)

Wha

t lev

el o

f cos

ts w

ill b

e in

curr

ed in

impl

emen

ting

the

inte

rven

tion?

(tick

resp

onse

) □

High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g thi

s? (I

f uns

ure,

w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)


OU

TER

SETT

ING

Th

e w

ider

eco

nom

ic, p

oliti

cal,

soci

al a

nd c

ultu

ral c

onte

xt in

fluen

ces i

mpl

emen

tatio

n.

A) P

ATIE

NT/

CLIE

NT

NEE

DS A

ND

RESO

URC

ESTh

e ex

tent

to w

hich

pati

ent n

eeds

, as w

ell a

s bar

riers

and

faci

litat

ors t

o m

eet t

hose

nee

ds, a

re a

ccur

atel

y kn

own

and

prio

ritise

d.

Howwerethene

edsa

ndpreferencesofp

atien

ts/

clientsc

onsid

ered

whe

nde

ciding

toim

plem

entthe

interven

tion?

To w

hat e

xten

t will

the

inte

rven

tion

mee

t the

ne

eds a

nd p

refe

renc

es o

f pa

tient

s/cl

ient

s?

(tick

resp

onse

) □

High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g th

is?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

B) C

OSM

OPO

LITA

NIS

M (E

XTER

NAL

NET

WO

RKS

AND

RELA

TIO

NSH

IPS)

The

qual

ity a

nd e

xten

t of r

elati

onsh

ips a

nd n

etw

orks

with

oth

er e

xter

nal o

rgan

isatio

ns (s

ocia

l cap

ital).

Wha

tkindofin

form

ation

excha

nge/ne

tworking

do

staff

havewith

otherso

utsid

etheirsetti

ng?

Wha

t is t

he le

vel o

f in

form

ation

exc

hang

e/ne

twor

king

staff

hav

e w

ith

othe

rs o

utsi

de o

f the

ir se

tting

/org

anis

ation

? (ti

ck re

spon

se)

□High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g th

is?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

82 Implementation Guide and Toolkit for National Clinical GuidelinesC)

PEE

R PR

ESSU

RECo

mpe

titive

pre

ssur

e to

impl

emen

t an

inte

rven

tion,

mai

nly

from

oth

er p

rofe

ssio

nals/

serv

ices

/org

anisa

tions

who

hav

e al

read

y im

plem

ente

d th

e in

terv

entio

n. T

his c

an a

id a

dopti

on o

f int

erve

ntion

s.

Areothe

rservices/professio

nalsim

plem

entin

gthe

interven

tionorsimilarp

racti

ces?

To w

hat e

xten

t are

oth

er

serv

ices

/pro

fess

iona

ls

impl

emen

ting

the

inte

rven

tion?

(tick

resp

onse

) □

High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g th

is?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

D) E

XTER

NAL

PO

LICI

ES A

ND

INCE

NTI

VES

Exte

rnal

pol

icie

s and

ince

ntive

s tha

t spr

ead

inte

rven

tions

, inc

ludi

ng g

over

nmen

t pol

icy

and

regu

latio

ns, e

xter

nal m

anda

tes,

reco

mm

enda

tions

an

d gu

idel

ines

, col

labo

rativ

es, a

nd p

ublic

or b

ench

mar

k re

porti

ng.

Arethereexternalpolicies,re

gulatio

nsor

guidelineswhichcou

ldim

pede

orc

onflictwith

im

plem

entatio

nofth

einterven

tion?

To w

hat e

xten

t are

ex

tern

al p

olic

ies a

nd

ince

ntive

s sup

porti

ng th

e im

plem

enta

tion

of th

e in

terv

entio

n?

(tick

resp

onse

) □

High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g th

is?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)


INN

ER S

ETTI

NG

The

orga

nisa

tiona

l str

uctu

re, c

ultu

re a

nd c

limat

e pl

ay a

n im

port

ant r

ole

in su

cces

sful

impl

emen

tatio

n.

A) S

TRU

CTU

RAL

CHAR

ACTE

RIST

ICS

The

age

and

size

of th

e or

gani

satio

n, le

vel o

f sta

ff tu

rnov

er, g

eogr

aphi

c sp

read

, phy

sical

layo

ut e

tc.

Wha

t kin

d of

infr

astr

uctu

re c

hang

es a

re n

eede

d to

acc

omm

odat

e th

e in

terv

entio

n (e

.g. c

hang

es to

po

licie

s, in

form

ation

and

reco

rd sy

stem

s)?

To w

hat e

xten

t is t

he

leve

l of i

nfra

stru

ctur

e re

quire

d to

impl

emen

t the

in

terv

entio

n in

pla

ce?

(ti

ck re

spon

se)

□High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g th

is?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

B) N

ETW

ORK

S AN

D CO

MM

UN

ICAT

ION

STh

e na

ture

and

qua

lity

of so

cial

net

wor

ks, a

nd fo

rmal

and

info

rmal

com

mun

icati

ons w

ithin

an

orga

nisa

tion.

How

do

staff

find

out

abo

ut n

ew in

itiati

ves,

ac

com

plis

hmen

ts, b

est p

racti

ce e

tc.?

How

do

you

rate

the

qual

ity o

f com

mun

icati

on

in th

e or

gani

satio

n?

(tick

resp

onse

) □

High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g th

is?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

84 Implementation Guide and Toolkit for National Clinical GuidelinesC)

CU

LTU

REN

orm

s, v

alue

s, a

nd b

asic

ass

umpti

ons o

f an

orga

nisa

tion.

How

do

you

thin

k th

e or

gani

satio

n’s c

ultu

re w

ill

affec

t the

impl

emen

tatio

n of

the

inte

rven

tion?

To

wha

t ext

ent a

re n

ew

idea

s em

brac

ed a

nd u

sed

to m

ake

impr

ovem

ents

?(ti

ck re

spon

se)

□High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g th

is?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

D) IM

PLEM

ENTA

TIO

N C

LIM

ATE

The

abso

rptiv

e ca

paci

ty fo

r cha

nge,

shar

ed re

cepti

vity

of i

nvol

ved

indi

vidu

als t

o an

inte

rven

tion,

and

the

exte

nt to

whi

ch u

se o

f tha

t int

erve

ntion

w

ill b

e re

war

ded,

supp

orte

d, a

nd e

xpec

ted

with

in th

eir o

rgan

isatio

n.

How

wel

l doe

s the

inte

rven

tion

fit w

ith e

xisti

ng

wor

k pr

oces

ses a

nd p

racti

ces?

To

wha

t ext

ent i

s the

or

gani

satio

n re

cepti

ve

to im

plem

entin

g th

e in

terv

entio

n?

(tick

resp

onse

) □

High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g th

is?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

85Implementation Guide and Toolkit for National Clinical GuidelinesE)

REA

DIN

ESS

FOR

IMPL

EMEN

TATI

ON

– L

eade

rshi

p en

gage

men

t; av

aila

ble

reso

urce

s; a

cces

s to

know

ledg

e an

d in

form

ation

Tang

ible

and

imm

edia

te in

dica

tors

of o

rgan

isatio

nal c

omm

itmen

t to

its d

ecisi

on to

impl

emen

t an

inte

rven

tion.

It in

volv

es:

i) le

ader

ship

eng

agem

ent,

i.e. c

omm

itmen

t, in

volv

emen

t and

acc

ount

abili

ty o

f lea

ders

;ii)

ava

ilabl

e re

sour

ces,

i.e.

reso

urce

s ded

icat

ed to

impl

emen

tatio

n (e

.g. f

or tr

aini

ng);

and

iii) a

cces

s to

know

ledg

e an

d in

form

ation

, i.e

. acc

ess t

o in

form

ation

and

kno

wle

dge

abou

t how

to im

plem

ent t

he in

terv

entio

n.

Do y

ou h

ave

the

nece

ssar

y re

sour

ces a

nd su

ppor

ts

requ

ired

to im

plem

ent t

he in

terv

entio

n?

To w

hat e

xten

t doe

s the

or

gani

satio

n en

dors

e or

su

ppor

t im

plem

enta

tion

of

the

inte

rven

tion?

(ti

ck re

spon

se)

□High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g th

is?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

86 Implementation Guide and Toolkit for National Clinical Guidelines4.

CHA

RACT

ERIS

TICS

OF

INDI

VIDU

ALS

The

char

acte

ristic

s of i

ndiv

idua

ls, in

clud

ing

thei

r cap

acity

and

moti

vatio

n, in

fluen

ce ch

ange

s in

beha

viou

r req

uire

d to

impl

emen

t int

erve

ntion

s.

A) C

APAC

ITY

– PH

YSIC

AL A

ND

PSYC

HOLO

GIC

ALTh

e ph

ysic

al a

nd p

sych

olog

ical

cap

acity

of i

ndiv

idua

ls to

del

iver

the

inte

rven

tion,

incl

udin

g ph

ysic

al st

reng

th, k

now

ledg

e, sk

ills a

nd st

amin

a.

Who

(i.e

. wha

t gro

ups)

are

nee

ded

to d

eliv

er th

e in

terv

entio

n?

To w

hat e

xten

t do

indi

vidu

als h

ave

the

capa

city

(phy

sica

l and

ps

ycho

logi

cal)

to e

nact

the

chan

ges r

equi

red?

(ti

ck re

spon

se)

□High

□Med

ium

□Low

Wha

t are

the

next

step

s for

stre

ngth

enin

g th

is?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)

B) M

OTI

VATI

ON

Brai

n pr

oces

ses t

hat e

nerg

ise a

nd d

irect

beh

avio

ur, i

nclu

ding

kno

wle

dge,

bel

iefs

, and

con

fiden

ce.

How

do

indi

vidu

als f

eel a

bout

impl

emen

ting

the

inte

rven

tion?

To

wha

t ext

ent a

re st

aff

moti

vate

d to

ena

ct th

e ch

ange

s req

uire

d?

(tick

resp

onse

) □

High

□Med

ium

□Low

Wha

t ar

e th

e ne

xt s

teps

for

str

engt

heni

ng t

his?

(If

unsu

re, w

hat a

dditi

onal

info

rmati

on d

o yo

u ne

ed?)


Guidance and Definitions for Implementation Enablers and Barriers Assessment Tool

1. Intervention Characteristics The characteristics of the intervention being implemented.

Intervention source Legitimacyandcredibilityoftheinterventionsource

Evidence strength and quality

Qualityandvalidityoftheevidenceindicatingthattheinterventionwillachievedesiredoutcomes

Relative advantage Interventionhasmoreadvantagethananotheralternative

Trialability Abilitytotesttheinterventiononasmallscaleintheorganisationandtobeabletoreversecourse(undoimplementation)ifwarranted

Complexity Difficultyofimplementation,reflectedbyduration,scope,radicalness,disruptiveness,centrality,numberofstepsrequiredtoimplement

Design quality and packaging

Excellenceinhowtheinterventionisbundled,presentedandassembled,includingwhatonlinesupportsareavailable

Cost Costsoftheinterventionitselfandcostsassociatedwithimplementingtheintervention,includinginvestment,supplyandopportunitycosts

2. Outer SettingThe economic, political, social and cultural context within which an organisation resides.

Patient needs and resources

Extenttowhichpatientneeds,aswellasbarriersandfacilitatorstomeetthoseneeds,areaccuratelyknownandprioritised

Cosmopolitanism Thequalityandextentofrelationshipsandnetworkswithotherexternalorganisations(socialcapital)

Peer pressure Competitivepressuretoimplementanintervention,mainlyfromoutsideprofessionals/services/organisationswhohavealreadyimplementedtheintervention

External policies and incentives

Externalstrategiestospreadinterventions,includingpolicyandregulations,externalmandates,recommendationsandguidelines,collaboratives,publicorbenchmarkingreporting

3. Inner Setting Structural, political and cultural context through which an implementation process will proceed

Structural characteristics

Socialarchitecture,age,maturity,size,staffturnoverofanorganisation

Networks and communications

Natureandqualityofsocialnetworks,andformalandinformalcommunicationswithinanorganisation(e.g.teamwork)

Culture Norms,valuesandbasicassumptionsofanorganisation


Implementation climate

Tension[perceivedneed]forchangeCompatibility–innovationfitwithexistingsystemsRelativeprioritywithintheorganisationOrganisationalincentivesandrewardsGoalscommunicated,andfeedbacktakenLearningclimateoftryingnewmethods,reflecting,learning

Readiness for implementation

LeadershipengagementAvailableresourcesforimplementationAccesstoinformationandknowledgeabouthowtoimplementtheintervention

4. Characteristics of Individuals Knowledge, beliefs and skills that individuals need in order to carry out the implementation process. May also refer to a team or unit

Knowledge and beliefs about the intervention

Individualbeliefsthattheinterventionwillbesuccessfulintheirsetting,givenexistingevidenceandplans

Self-efficacy Individualbeliefintheirown,andtheircolleagues’,abilitytoimplementtheinnovation

Individual stage of change

Thephaseanindividualisin,accordingtoRogers’/Prochaska’sStagesofChange,theyprogresstowardsskilled,enthusiasticandsustaineduseoftheintervention

Individual identification with organisation

Howindividualsperceivetheorganisation,theirrelationshipwithitandthedegreeofcommitmenttotheorganisation

Other personal attributes

Includingtoleranceofambiguity,intellectualability,motivation,values,competence,andlearningstyle

References[1] Damschroder,L.J.,Aron,D.C.,Keith,R.E.,Kirsh,S.R.,Alexander,J.A.,&Lowery,J.C.(2009).

Fostering implementation of health services research findings into practice: a consolidatedframework for advancing implementation science. Implementation Science, 4(1), pp. 50-64.Availablefrom:https://doi.org/10.1186/1748-5908-4-50

[2] Michie, S., van Stralan M., West R. (2011). The behaviour change wheel: A new methodfor characterising and designing behaviour change interventions. Implementation Science, 6(1), p.42. Available from: https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42

https://doi.org/10.1186/1748-5908-4-50

https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42

https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-6-42


Tool 4 – Implementation Planning Tool Implementation is a key requirement for Guideline Groups and completed published guidelinesmustincludeanimplementationplan.Groupsshouldfilloutthetemplateprovidedonthefollowingpage, listingspecificactionsthatarerequiredfor implementation,andlinkingthemto:guidelinerecommendations(anumberofrecommendationscanbegroupedtogether,whereappropriate);who is ultimately responsible for leading the action; the expected timeframe for completion;and themeasure/indicator that will be used to verify that the recommendation has been fullyimplemented.Thesearedescribedingreaterdetailbelow.

Explanatory notes for implementation plan • Guideline recommendation/number:Thisreferstothespecificguidelinerecommendation(s)

which the action/intervention aims to achieve. One action may address several recommendations, e.g. training programme or additional staff. Ensure all guidelinerecommendationsareincludedintheimplementationplan.

• Barriers and enablers: Identify the barriers and enablers for implementing this recommendation.Completingthe ‘ImplementationEnablersandBarriers:AssessmentTool’inTool3will helpyou to complete this section.Note that somebarriersandenablerswillbecommontomultiplerecommendations.Considercapability,opportunityandmotivation,whichinfluencebehaviour.

• Action/intervention/task to implement recommendation: This is the specific high-levelaction,interventionortaskwhichisneededtoimplementtheguidelinerecommendation(s).Determinetheactions,interventionsortasksthatareeffectiveandbestsuitedtoaddresstheidentifiedneedsandbarriers.Theactions, interventionsortasksshouldspecifythechangerequiredtocurrentpractice,i.e.whoneedstodowhatdifferentlyforthisrecommendationtobeimplementedeffectively.

• Lead responsibility for delivery of the action/intervention/task:Manyactions,interventionsor tasks are carriedout bymultidisciplinary teams andmultiple stakeholders. This columnshouldbeusedtospecifytheleadgroup/unit/organisationresponsibleforimplementingtheaction/intervention/task.EnsuringthatthesestakeholdersareonyourGuidelineGroupfromthebeginningwillhelptoensurethattheguidelinerecommendationsareimplementable.

• Timeframe for completion: Specifythetimeframeyouexpectforfullimplementationofthisaction,interventionortaskwithinthethreeyearsfollowingpublication.Foradditionaldetail,thequarter(Q1,Q2,Q3,orQ4)canalsobeadded.Itisusefultospreadtheseoutoverthe3years.Someinterventionsmaybedependentonadditionalfundingandcanbedenotedassuch.Theguidelineisupdatedafter3years,withanewimplementationplan.

• Expected outcome and verification:Specifytheexpectedoutcomeandhowyouwillverifyormeasureit,i.e.howwillyouknowwhentherecommendationhasbeenfullyimplemented?Howwillyouknowiftheexpectedoutcomehasbeenachieved?Useexistingdata/measurementsourceswhereavailable.

• Allowing adequate and appropriate time for planning how clinical guidelines will be implemented is a crucial implementation enabler,enablingthosewhoaredrivingthechangetomapouttheimplementationprocessandprovideacourseofactiontoaddressanypotentialchallenges.



90 Implementation Guide and Toolkit for National Clinical GuidelinesIm

plem

enta

tion

Plan

(for

incl

usio

n in

the

publ

ishe

d gu

idel

ine)

Gui

delin

e re

com

men

datio

n or

num

ber(

s)

Impl

emen

tatio

n ba

rrie

rs/

enab

lers

/gap

s

Actio

n/in

terv

entio

n/ta

sk to

im

plem

ent r

ecom

men

datio

n Le

ad

resp

onsi

bilit

y fo

r de

liver

y of

the

actio

n

Tim

efra

me

for

com

pleti

onEx

pect

ed

outc

ome

and

verifi

catio

n Ye

ar

1Ye

ar

2Ye

ar

3

91Implementation Guide and Toolkit for National Clinical GuidelinesIm

plem

enta

tion

of th

e ov

eral

l gui

delin

eWhilethe

implem

entatio

nplan

isspecifictothe

ind

ividua

lrecommen

datio

nsin

the

guideline,som

eactio

nsw

illassistw

ithguide

line

implem

entatio

nasaw

hole.T

hesein

clud

eestablish

ingan

implem

entatio

nteam

;de

veloping

adiss

eminati

onand

com

mun

icati

onplanan

dde

veloping

spe

cificim

plem

entatio

ntoolsan

dresources.In

the

boxesbelow

,pleasegiveahigh-leveld

escriptio

nofhow

the

seacti

onswillbe

incorporated

intoth

eim

plem

entatio

nofyou

rguide

line:

Impl

emen

tatio

n te

am:De

scrib

ethestructurean

dgo

vernan

ceofyourim

plem

entatio

nteam

,ou

tline

processforrisk

iden

tificatio

nan

dman

agem

ent,listyourim

plem

entatio

nteam

mem

bersand

spe

cifym

eetin

gfreq

uency.O

utlin

eplan

nedtraining

and

cap

acity

buildingfor

team

mem

bers.

Diss

emin

ation

and

com

mun

icati

on p

lan:Describeyourcom

mun

icati

onsstrategyand

diss

eminati

onplanford

istrib

uting

,sha

ring,promoti

ng

andap

plying

guide

linerecommen

datio

nse.g.rep

ortin

gsche

dule,p

ublicati

ons/artic

les,presentati

ons,awaren

ess-raising

acti

vitie

s,m

edia,

know

ledg

etran

sfer,collabo

ratio

nan

dne

tworking

.

Impl

emen

tatio

n to

ols:Listthe

sup

porting

too

lsan

dresourcesde

velope

dtosup

portthisgu

ideline/projectan

dwhe

rethe

setoo

lscanbe

accessed

,e.g.m

aterialson

web

site,pati

entinformati

onleafl

ets,training

linked

toCPD

,e-le

arning

,pod

casts,stud

yda

ys,resea

rch,che

cklists,

audittoo

ls,m

onito

ringan

drepo

rting

processes,sem

inars,con

ference,pati

entp

athw

ays,to

olkits,algorith

ms,te

aching

aids,presentati

ons.


Tool 5 – Monitoring and Evaluating Implementation: Planning ToolIntroductionThistoolhasbeenproducedbytheCentreforEffectiveServices,basedonProctoretal.’s(2011)taxonomy of implementation outcomes and the Reach Efficacy Adoption ImplementationMaintenance (RE-AIM) framework (Glasgow, Vogt & Boles, 1999). It has been produced tohelp those involved in developing and implementingNational ClinicalGuidelines toplan for themonitoringandevaluationofimplementationoftheirguideline.

It relatesspecificallytotheeight implementationoutcomeareasrelevanttothe implementationofNationalClinicalGuidelinesthatarelistedbelow.Foreachoutcomearea,thelevelsofanalysisare listed, some questions regarding monitoring and evaluation, and potential data collectionmethods are listed. It is important to remember that many of the outcomes below are inter-related. Further, someof these outcomes aremore relevant for early stages of implementation(e.g. appropriateness) and others are more relevant for later stages of implementation (e.g.sustainability).

Theseimplementationoutcomeareasareseparatefromserviceoutcomes(e.g.efficiency,safety,effectiveness, equity, patient-centredness, timeliness) and client outcomes (e.g. satisfaction,function,symptomatology).TheyarealsoseparatefromserviceandprocessmeasuresrequiredinNCECpublishedguidelines. Implementationoutcomesrelatespecificallyto implementationofaninterventionandarekeyareasforconsiderationintheimplementationprocess.

ThistoolcanbeusedbyGuidelineGroupstoconsiderimportantfactorsinimplementationoftheirguideline,andtocreateactionplansforhowtomonitorandevaluatethesefactors.Thiswilltheninformtheactualcollection,collation,analysisandreportingofdataonimplementation.

Implementation Outcomes

Acceptability

Fidelity

Feasibility

Reach

Implementation Cost

Adoption

Effectiveness

Sustainability




Acc

epta

bilit

y

The

perc

eptio

n am

ong

stak

ehol

ders

that

an

inte

rven

tion

is ag

reea

ble,

pal

atab

le o

r sati

sfac

tory

, and

lead

s to

an

impr

oved

gen

eral

ser

vice

ex

perie

nce

Levelo

fAna

lysis

•Individu

alPati

ent/

Serviceuser

•Individu

alProvide

r

Mon

itorin

gan

dEvalua

tionQue

stion

s

•Wha

tlevelofk

nowledg

edo

provide

rshaveab

outthe

con

tentand

com

plexity

ofthe

interven

tion?

•Wha

tareprovide

rs’attitude

stow

ardtheinterven

tion?

•Do

provide

rsra

teth

eeviden

cefo

rthe

interven

tionasstrong

?•

From

thepa

tient/serviceuser’sperspectiv

e,doe

sthe

interven

tionim

proveho

w

patie

nts/serviceuserse

xperienceaservice?

Potenti

alM

etho

ds

•Su

rvey

•Interviews

•Ad

ministrativ

eDa

ta

Actio

n Pl

anni

ng (W

hata

ction

sdo

theGu

idelineGrou

pan

dothe

rstakeho

ldersne

edto

taketo

helpaccuratelyassessacceptab

ility?Ac

tions

shou

ldbeinform

edbylevelo

fana

lysis

,answerstothequ

estio

nsposed

abo

veand

poten

tialm

etho

dsfo

rdatacollecti

on):


App

ropr

iate

ness

/Fea

sibi

lity

Th

e ex

tent

to w

hich

the

inte

rven

tion

is co

mpa

tible

, rel

evan

t and

impl

emen

tabl

e w

ithin

a g

iven

con

text

or s

etting

Levelo

fAna

lysis

•Individu

al

Patie

nt/S

ervice

User

•Individu

al

Provider

•Organ

isatio

n/

Setting

Mon

itorin

gan

dEvalua

tionQue

stion

s

•Do

esth

eorganisatio

nha

veth

eresources,staff

and

equ

ipmen

ttoim

plem

entthe

interven

tion?

•Do

staff

havethetim

e,sk

ills,training

and

abilitytoim

plem

entthe

interven

tion?

•Isth

erean

yaspe

ctofthe

interven

tionthatcou

ldm

akeitinap

prop

riatefo

rprovide

rsor

thetargetpop

ulati

on?(e.g.d

ueto

culture,religion,beliefs,value

setc.)

Potenti

alM

etho

ds

•Su

rvey

•Interviews

•FocusG

roup

s

Actio

n Pl

anni

ng (Wha

tactio

nsdotheGu

idelineGrou

pan

dothe

rstakeh

olde

rsnee

dtotaketohelpaccuratelyassessap

prop

riatene

ss/

feasibility?Ac

tionssh

ouldbeinform

edbylevelo

fana

lysis

,answerstothequ

estio

nsposed

abo

veand

poten

tialm

etho

dsfo

rdatacollecti

on):


Ado

ption

Th

e in

itial

dec

ision

s by

prov

ider

s to

utilis

e th

e in

terv

entio

n in

the

first

pla

ce, a

nd th

en w

here

it is

impl

emen

ted

and

who

is im

plem

entin

g it

Levelo

fAna

lysis

•Organ

isatio

n/

Setting

•Individu

al

Provider

Mon

itorin

gan

dEvalua

tionQue

stion

s

•Who

isth

etargetgroup

and

inwha

tsetti

ngsa

reth

eybeing

targeted

?•

Who

can

helpgatherinform

ation

abo

utth

is?•

Who

willdeliverth

einterven

tion,and

dotheyhavetheskillsa

ndtime?

•Ho

wwillyou

kno

wifstaff

usedtheinterven

tion?

Potenti

alM

etho

ds

•Su

rvey

•Observatio

n•

Interviews

•FocusG

roup

s•

Administrativ

eDa

ta

Actio

n Pl

anni

ng:(Wha

tactio

nsdotheGu

idelineGrou

pan

dothe

rstakeh

olde

rsnee

dtotaketohelpaccuratelyassessad

optio

n?Acti

ons

shou

ldbeinform

edbylevelo

fana

lysis

,answerstothequ

estio

nsposed

abo

veand

poten

tialm

etho

dsfo

rdatacollecti

on):


Fid

elity

Th

e de

gree

to w

hich

the

inte

rven

tion

is co

nsist

ently

del

iver

ed a

s it w

as o

rigin

ally

inte

nded

and

des

igne

d to

be

deliv

ered

Levelo

fAna

lysis

•Individu

al

Provider

Mon

itorin

gan

dEvalua

tionQue

stion

s

•Wha

tareth

ekeyelem

entsofthe

interven

tionthatm

ustb

ede

livered

tobesuccessful?

•Wha

tcostsand

resourcesa

ssociatedwith

ada

pting

theinterven

tion(in

clud

ingtim

ean

dbu

rden

,notju

stm

oney)n

eedtobeconsidered

and

includ

edin

theBu

dgetIm

pact

Analysis?

•Ho

wwillyou

assessd

eliveryofth

einterven

tion?

Potenti

alM

etho

ds

•Observatio

n•

Checklists

•Co

nten

tAna

lyses

•FocusG

roup

s•

Self-Re

port

Actio

n Pl

anni

ng(W

hata

ction

sdo

theGu

idelineGrou

pan

dothe

rstakeho

ldersne

edto

taketo

helpaccuratelyassessfid

elity

?Ac

tionssho

uld

beinform

edbylevelo

fana

lysis

,answerstothequ

estio

nsposed

abo

veand

poten

tialm

etho

dsfo

rdatacollecti

on):


Pen

etra

tion/

Reac

h

The

degr

ee to

whi

ch th

e in

terv

entio

n is

inte

grat

ed in

to a

serv

ice

setti

ng, i

nclu

ding

whe

ther

it e

ffecti

vely

reac

hed

the

targ

et p

opul

ation

Levelo

fAna

lysis

•Individu

al

Patie

nt/S

ervice

User

•Patie

nt/Service

UserP

opulati

on

Mon

itorin

gan

dEvalua

tionQue

stion

s

•Who

isth

etargetgroup

?De

finetheintend

edben

eficiaries/targetpop

ulati

on(s),an

dwha

tsectorsoftha

ttargetp

opulati

onyou

intend

tore

ach.

•Ho

wand

whe

rewillyou

reachthem

?•

Howcon

fiden

tareyou

thatyou

willbeab

leto

dothis?

•Ho

wwillyou

kno

wifth

osewho

areusin

gtheinterven

tionarerepresen

tativ

eofth

eintend

edben

eficiaries/targetpop

ulati

on(s)?(thisc

anbeba

sedon

stakeh

olde

rana

lysis

activ

ities)

•Ho

wwillyou

kno

wifyou

reache

dtheap

prop

riateta

rgetsites?

•Wha

tmetho

dswillyou

useto

attractund

erserved

pop

ulati

onsa

ndfo

cuso

nhe

alth

ineq

uitie

s?

Potenti

alM

etho

ds

•Su

rvey

•Ca

seStudies

•Interviews

•Ad

ministrativ

eDa

ta

Actio

n Pl

anni

ng (Wha

tactio

nsdotheGu

idelineGrou

pan

dothe

rstakeh

olde

rsnee

dtotaketohelpaccuratelyassesspe

netrati

on/rea

ch?

Actio

nssh

ouldbeinform

edbylevelo

fana

lysis

,answerstothequ

estio

nsposed

abo

veand

poten

tialm

etho

dsfo

rdatacollecti

on):


Im

plem

enta

tion

Effec

tiven

ess

Th

e de

gree

to w

hich

pre

-defi

ned

outc

omes

are

ach

ieve

d as

a re

sult

of im

plem

entin

g th

e in

terv

entio

n

Levelo

fAna

lysis

•Individu

al

Patie

nt/S

ervice

User

•Patie

nt/S

ervice

UserP

opulati

on•

Organ

isatio

n/

Setting

Mon

itorin

gan

dEvalua

tionQue

stion

s

•Wha

tareth

emostimpo

rtan

toutcomesyou

expecttosee?

•Ho

wwillyou

defi

nesu

ccessinachievingtheseou

tcom

es?

•Ho

wlikelyisitth

atyou

rinitia

tivewillachieveitsk

eyoutcomes?

•Ho

wwillyou

mea

sureth

esechan

ges?

•Who

willth

eou

tcom

esm

atterto

?•

Howwillyou

sharetheseou

tcom

es?

•Wha

tareth

ebiggestthreatsto

seeing

theou

tcom

esyou

wan

t?

•Wha

tuninten

dedconseq

uencesoro

utcomesm

ightth

erebe

?

Potenti

alM

etho

ds

•Su

rvey

•Ca

seStudies

•Interviews

•FocusG

roup

s•

Administrativ

eDa

ta

Actio

n Pl

anni

ng (Wha

tactio

nsdotheGu

idelineGrou

pan

dothe

rstakeh

olde

rsnee

dtotaketohelpaccuratelyassessim

plem

entatio

neff

ectiv

eness?A

ction

sshou

ldbeinform

edbylevelofana

lysis

,an

swerstothe

que

stion

spo

sedab

ovean

dpo

tenti

alm

etho

dsfordata

collecti

on):


Im

plem

enta

tion

Cost

Th

e re

sour

ces a

nd fu

ndin

g re

quire

d to

impl

emen

t the

inte

rven

tion,

and

the

net c

ost i

mpa

ct o

f im

plem

entin

g an

d de

liver

ing

the

inte

rven

tion

Levelo

fAna

lysis

•Individu

al

Patie

nt/S

ervice

User

•Organ

isatio

n/

setting

Mon

itorin

gan

dEvalua

tionQue

stion

s

•Ho

wm

uchwillitcosttode

livereachrecommen

datio

n?•

Howwillth

ecostsv

aryacrossdifferen

tsetti

ngs?

•Wha

tisthe

coste

ffecti

vene

ssofthe

propo

sedinterven

tion?

•Aretherean

ycostsa

ving

santi

cipa

tedwith

thisinterven

tion?

•

Wha

tareth

etim

escalesforth

eserviceplan

ning

/fun

ding

cycles(toensuretim

ely

subm

issionofyou

rbud

getimpa

ctassessm

enttotheserviceplan

ning

process)?

Potenti

alM

etho

ds

•Ad

ministrativ

eda

ta•

HIPE

data

•HT

A

(Resou

rceson

cond

uctin

gBu

dget

Impa

ctAssessm

ent

andecon

omic

evalua

tionavailableon

th

e NCE

Cweb

site)

Actio

n Pl

anni

ng (W

hata

ction

sdo

theGu

idelineGrou

pan

dothe

rstakeho

ldersne

edto

taketo

helpaccuratelyassessim

plem

entatio

ncost?

Actio

nssh

ouldbeinform

edbylevelo

fana

lysis

,answerstothequ

estio

nsposed

abo

veand

poten

tialm

etho

dsfo

rdatacollecti

on):



Mai

nten

ance

/Sus

tain

abili

ty

The

exte

nt to

whi

ch th

e in

terv

entio

n w

ill b

e re

new

ed a

nd in

stitu

tiona

lised

into

the

orga

nisa

tion/

setti

ng’s

ongo

ing

oper

ation

s

Levelo

fAna

lysis

•Organ

isatio

n/

setting

Mon

itorin

gan

dEvalua

tionQue

stion

s

•Wha

twillhap

penoverth

elong

-term

?Co

nsiderfo

rbothindividu

alben

eficiariesa

nd

setting

s.•

Canorganizatio

nssu

staintheinitiati

veoverti

me?Isth

erean

infrastructureofstaffan

dresourcesinplace?

•Ho

wlikelyisyou

rinitia

tivetoprodu

celasting

effe

ctsforin

dividu

alpati

entsand

provide

rs?

•Ho

wwillyou

beab

leto

follo

wyou

rinitia

tivefora

nextend

edperiodoftime?

•Ho

wwillyou

con

tinue

totracksuccess;cha

ngesm

adeovertime;and

provide

ong

oing

feed

back?

•Ho

wwillyou

getth

ewordou

tabo

utyou

rinterventi

onand

lesson

slea

rned

?

Potenti

alM

etho

ds

•Su

rvey

•Ca

seStudies

•Re

cordand

Policy

Review

s•

Interviews

Actio

n Pl

anni

ng (Wha

tactio

nsd

otheGu

idelineGrou

pan

dothe

rstakeh

olde

rsn

eed

totaketoh

elp

accuratelyassessmainten

ance/

sustaina

bility?A

ction

sshou

ldbeinform

edbylevelofana

lysis

,an

swerstothe

que

stion

spo

sedab

ovean

dpo

tenti

alm

etho

dsfordata

collecti

on):

101Implementation Guide and Toolkit for National Clinical GuidelinesRe

leva

nt A

rticl

es/L

inks

Thefollo

wingartic

lesareexam

plesofh

owthe

RE-AIMfram

eworkan

dProctor’sta

xono

myofim

plem

entatio

nou

tcom

eshavebe

enusedan

dad

aptedtom

onito

rand

evaluateim

plem

entatio

nofinterven

tionsin

thehe

althse

ctor:

• Glasgo

w,R.E.,McKay,H

.G.,Piett

e,J.D.,&

Reyno

lds,K.D.(20

01).Th

eRE

-AIM

fram

eworkfore

valuati

nginterven

tions:w

hatcan

itte

llusabo

ut

approa

chesto

chron

icillnessm

anagem

ent?P

atien

t Edu

catio

n an

d Co

unse

lling

,44(2),1

19-127

.Retrie

vedfrom

:http://www.scien

cedirect.

com/scien

ce/article/pii/S

0738

3991

0000

1865

•Glasgo

w,R.E

.,Vo

gt,T

.M.,&Boles,S

.M.(19

99).Evalua

tingthepu

blichea

lthim

pactofhe

althpromoti

onin

terven

tions:the

RE-AIM

fram

ework.American

journa

lofp

ublichea

lth,8

9(9),1

322-13

27.R

etrie

vedfrom

:http://ajph

.aph

apub

licati

ons.org/do

i/pdfplus/10.21

05/

AJPH

.89.9.13

22

• Jeon

g,H.J.,Jo,H.S.,Oh,M

.K.,&Oh,H.W.(20

15).Ap

plying

theRE

-AIM

Framew

orktoevaluatethedissem

inati

onand

implem

entatio

nof

clinicalpracti

ceguide

linesfo

rsexua

llytran

smitted

infecti

ons.Jo

urna

l of K

orea

n M

edic

al S

cien

ce,3

0(7),8

47-852

.Retrie

vedfrom

:https://

https://doi.org/10.33

46/jk

ms.20

15.30.7.84

7

• Proctor,E.,Silm

ere,H.,Ra

ghavan

,R.,Ho

vman

d,P.,A

aron

s,G.,Bu

nger,A

.,...&Hen

sley,M.(20

11).Outcomesfo

rimplem

entatio

nresearch:

concep

tualdisti

nctio

ns,m

easuremen

tchalleng

es,a

ndresea

rchagen

da.A

dmin

istra

tion

and

Polic

y in

Men

tal H

ealth

and

Men

tal H

ealth

Se

rvic

es R

esea

rch,3

8(2),65

-76.R

etrie

ved

from

:htt

p://eff

ectiv

eservices.org/do

wnloa

ds/O

utcomes_for_Implem

entatio

n_Re

search__

Concep

tual_D

istinctio

ns__

mea

suremen

t_challeng

es_a

nd_resea

rch_

agen

da.pdf

http://www.sciencedirect.com/science/article/pii/S0738399100001865

http://www.sciencedirect.com/science/article/pii/S0738399100001865

http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.89.9.1322

http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.89.9.1322


https://doi.org/10.3346/jkms.2015.30.7.847

http://effectiveservices.org/downloads/Outcomes_for_Implementation_Research__Conceptual_Distinctions__measurement_challenges_and_research_agenda.pdf

http://effectiveservices.org/downloads/Outcomes_for_Implementation_Research__Conceptual_Distinctions__measurement_challenges_and_research_agenda.pdf


www.health.gov.ie

Documents

Implementation Guide and Toolkit for National Clinical