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. 1999 Sep;8(3):177–183. doi: 10.1136/qshc.8.3.177

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

N T Moulding, C A Silagy, D P Weller
PMCID: PMC2483658  PMID: 10847875

Abstract

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

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Selected References

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  1. Cohen S. J., Halvorson H. W., Gosselink C. A. Changing physician behavior to improve disease prevention. Prev Med. 1994 May;23(3):284–291. doi: 10.1006/pmed.1994.1040. [DOI] [PubMed] [Google Scholar]
  2. Conroy M., Shannon W. Clinical guidelines: their implementation in general practice. Br J Gen Pract. 1995 Jul;45(396):371–375. [PMC free article] [PubMed] [Google Scholar]
  3. Davis D. A., Thomson M. A., Oxman A. D., Haynes R. B. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995 Sep 6;274(9):700–705. doi: 10.1001/jama.274.9.700. [DOI] [PubMed] [Google Scholar]
  4. Davis D. A., Thomson M. A., Oxman A. D., Haynes R. B. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA. 1992 Sep 2;268(9):1111–1117. [PubMed] [Google Scholar]
  5. Day F., Hoang L. P., Ouk S., Nagda S., Schriger D. L. The impact of a guideline-driven computer charting system on the emergency care of patients with acute low back pain. Proc Annu Symp Comput Appl Med Care. 1995:576–580. [PMC free article] [PubMed] [Google Scholar]
  6. Elson R. B., Connelly D. P. Computerized patient records in primary care. Their role in mediating guideline-driven physician behavior change. Arch Fam Med. 1995 Aug;4(8):698–705. doi: 10.1001/archfami.4.8.698. [DOI] [PubMed] [Google Scholar]
  7. Evidence-Based Medicine Working Group Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992 Nov 4;268(17):2420–2425. doi: 10.1001/jama.1992.03490170092032. [DOI] [PubMed] [Google Scholar]
  8. Felch W. C. Bridging the gap between research and practice. The role of continuing medical education. JAMA. 1997 Jan 8;277(2):155–156. [PubMed] [Google Scholar]
  9. Firth-Cozens J. Healthy promotion: changing behaviour towards evidence-based health care. Qual Health Care. 1997 Dec;6(4):205–211. doi: 10.1136/qshc.6.4.205. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Grimshaw J. M., Russell I. T. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993 Nov 27;342(8883):1317–1322. doi: 10.1016/0140-6736(93)92244-n. [DOI] [PubMed] [Google Scholar]
  11. Grol R. Personal paper. Beliefs and evidence in changing clinical practice. BMJ. 1997 Aug 16;315(7105):418–421. doi: 10.1136/bmj.315.7105.418. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Gupta L., Ward J., Hayward R. S. Future directions for clinical practice guidelines: needs, lead agencies and potential dissemination strategies identified by Australian general practitioners. Aust N Z J Public Health. 1997 Aug;21(5):495–499. doi: 10.1111/j.1467-842x.1997.tb01741.x. [DOI] [PubMed] [Google Scholar]
  13. Hayward R. S., Wilson M. C., Tunis S. R., Guyatt G. H., Moore K. A., Bass E. B. Practice guidelines. What are internists looking for? J Gen Intern Med. 1996 Mar;11(3):176–178. doi: 10.1007/BF02600272. [DOI] [PubMed] [Google Scholar]
  14. Johnston M. E., Langton K. B., Haynes R. B., Mathieu A. Effects of computer-based clinical decision support systems on clinician performance and patient outcome. A critical appraisal of research. Ann Intern Med. 1994 Jan 15;120(2):135–142. doi: 10.7326/0003-4819-120-2-199401150-00007. [DOI] [PubMed] [Google Scholar]
  15. Lomas J., Haynes R. B. A taxonomy and critical review of tested strategies for the application of clinical practice recommendations: from "official" to "individual" clinical policy. Am J Prev Med. 1988;4(4 Suppl):77–97. [PubMed] [Google Scholar]
  16. Marshall M. N. Qualitative study of educational interaction between general practitioners and specialists. BMJ. 1998 Feb 7;316(7129):442–445. doi: 10.1136/bmj.316.7129.442. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. McColl A., Smith H., White P., Field J. General practitioner's perceptions of the route to evidence based medicine: a questionnaire survey. BMJ. 1998 Jan 31;316(7128):361–365. doi: 10.1136/bmj.316.7128.361. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Mittman B. S., Tonesk X., Jacobson P. D. Implementing clinical practice guidelines: social influence strategies and practitioner behavior change. QRB Qual Rev Bull. 1992 Dec;18(12):413–422. doi: 10.1016/s0097-5990(16)30567-x. [DOI] [PubMed] [Google Scholar]
  19. Oxman A. D., Thomson M. A., Davis D. A., Haynes R. B. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995 Nov 15;153(10):1423–1431. [PMC free article] [PubMed] [Google Scholar]
  20. Petrie J. C., Grimshaw J. M., Bryson A. The Scottish Intercollegiate Guidelines Network Initiative: getting validated guidelines into local practice. Health Bull (Edinb) 1995 Nov;53(6):345–348. [PubMed] [Google Scholar]
  21. Prochaska J. O., DiClemente C. C. Stages and processes of self-change of smoking: toward an integrative model of change. J Consult Clin Psychol. 1983 Jun;51(3):390–395. doi: 10.1037//0022-006x.51.3.390. [DOI] [PubMed] [Google Scholar]
  22. Prochaska J. O., Velicer W. F., Rossi J. S., Goldstein M. G., Marcus B. H., Rakowski W., Fiore C., Harlow L. L., Redding C. A., Rosenbloom D. Stages of change and decisional balance for 12 problem behaviors. Health Psychol. 1994 Jan;13(1):39–46. doi: 10.1037//0278-6133.13.1.39. [DOI] [PubMed] [Google Scholar]
  23. Robertson N., Baker R., Hearnshaw H. Changing the clinical behavior of doctors: a psychological framework. Qual Health Care. 1996 Mar;5(1):51–54. doi: 10.1136/qshc.5.1.51. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Stocking B. Implementing the findings of Effective Care in Pregnancy and Childbirth in the United Kingdom. Milbank Q. 1993;71(3):497–521. [PubMed] [Google Scholar]
  25. Stocking B. Why research findings are not used by commissions--and what can be done about it. J Public Health Med. 1995 Dec;17(4):380–382. [PubMed] [Google Scholar]
  26. Stokols D. Establishing and maintaining healthy environments. Toward a social ecology of health promotion. Am Psychol. 1992 Jan;47(1):6–22. doi: 10.1037//0003-066x.47.1.6. [DOI] [PubMed] [Google Scholar]
  27. Wensing M., Grol R. Single and combined strategies for implementing changes in primary care: a literature review. Int J Qual Health Care. 1994 Jun;6(2):115–132. doi: 10.1093/intqhc/6.2.115. [DOI] [PubMed] [Google Scholar]

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