Guidelines implementation toolbox

Introduction

The Guidelines (GLs) implementation toolbox, developed by the UEG Quality of Care Task Force, contains a checklist of questions that should be taken into consideration when applying international, specialist society guidelines to national or local practice. It also includes a list of practical examples/tools as to how GLs can be adapted, displayed and distributed for easier use in daily clinical practice. UEG encourages everyone to consult this checklist before starting an implementation project.

Questions that should be considered before implementing a GL nationally/locally

1. Why is the exact GL topic relevant in the country/region/clinic where it will be implemented? (Why this topic? Why not others?)

   1. High disease incidence/prevalence?

   2. High disease burden (morbidity, mortality, costs, quality of life etc.)?

   3. Underdiagnosed/undertreated?

   4. Missing local practice/missing local expert opinion?

   5. Etc.

2. What is the target audience for the exact GL that will be implemented?

   1. General practitioners (family doctors)?

   2. Primary care gastroenterologists?

   3. Gastroenterologists working in hospitals?

   4. Endoscopists?

   5. Hepatologists?

   6. Researchers/research institutions?

   7. Patients?

   8. Hospital administrators?

   9. Policy makers?

   10. Etc.

3. Assess the baseline: what is the current situation/current practice associated with the problem the GL is addressing?

   1. Survey the target audience about their current practice?

   2. Patient involvement and patient reported outcomes?

   3. 3–5 key objective measurable metrics (taken from the exact GL) that could be changed. What is the situation before the GL is implemented?

4. Look for partners and financial support for GL implementation:

   1. Hospitals and medical centers?

   2. Research centers?

   3. Medical universities?

   4. Government?

      1. National Health Ministry?

      2. Centers for the Disease control and Prevention?

   5. Non-governmental organizations?

   6. Patient organizations?

   7. International specialist societies?

   8. UEG?

5. Adapt and implement the GL:

   1. Consider the quality of the GL before the actual implementation. Use high quality GLs developed according to evidence-based methodology, GLs that are not industry sponsored, GLs that state author’s conflict of interest, etc.

   2. Consider measurable aspects of the GL to assess before the implementation and monitor adherence afterwards. When implementing a GL, stakeholders should use exact measurable metrics and observe a positive change in them after the GL implementation. Surveys might be considered more subjective as opposed to measurable trends in the change of action.

   3. Implement recommendations that do not depend on resources first. Especially consider this in countries/areas with lower healthcare resources.

   4. Adapt the GL for local use. Tools like ADAPTE guidelines could be used: https://g-i-n.net/document-store/working-groups-documents/adaptation/resources/adapte-resource-toolkit-guideline-adaptation-2-0.pdf/view

   5. Adapt the GL for easier use in daily clinical practice. See the list of practical examples/tools with links below.

6. GL implementation strategies/channels: what strategies/channels will be used to disseminate the exact GL? What is the exact reach using each of the channels? How many people from the target audience will be reached via the exact channel? (Expected numbers)

   1. Conferences, online courses?

   2. Meetings at hospitals/clinics/individual doctors?

   3. Journals, booklets (online/printed)?

   4. National Society online web page guidelines section?

   5. Social media – Twitter, Facebook, Instagram etc.?

   6. Gastroenterology GLs app?

7. What are the key messages when approaching the target audience?

   1. 1–3 key messages that should be remembered after the GL implementation campaign

   2. Provide short versions/take away/easy to use/summarized tables/practical tools/apps for doctors to use in their everyday clinical practice (see practical tools section)

   3. In each of the GL implementation channels provide and encourage a feed-back possibility (test before – after, comment possibility etc.)

8. After the implementation: what is the real reach of the target audience via the GL implementation channels discussed in point 6? Do and how do the real numbers differ from the expected ones?

9. Asses the outcome: how has the situation/practice changed after the exact GL implementation? (right after the implementation? 1, 3, 6, 12 months after the implementation? 3, 5, 10 years after the implementation?)

   1. Survey the target audience about their practice after the GL implementation

      1. Do doctors remember the 1–3 key messages provided during the GL implementation campaign?

      2. Do doctors use the short versions provided? This can be automatically measured if apps/internet resources are used.

   2. Have the 3–5 key objective measurable metrics (taken from the exact GL) changed? How?

   3. Has the incidence/prevalence/burden/cost of the disease/problem the GL is addressing changed? How?

10. What other projects might be developed/have been developed from this GL implementation project?

List of practical examples/tools for easier GL use in daily clinical practice (non-exhaustive)

• GI Guidelines App: https://ueg.eu/guidelines-app

• Guideline app iCyst: https://apps.apple.com/us/app/icyst/id1479833485

• ECCO e-guide: http://www.e-guide.ecco-ibd.eu/

• ESPGHAN clinical advice: http://www.espghan.org/societal-papers/clinical-advice-guides/

• EASL slide decks: https://easl.eu/science-and-education/slide-decks/

• BMJ Visual abstracts: https://www.bmj.com/content/bmj-visual-abstracts

• BMJ Rapid recommendations: https://www.bmj.com/rapid-recommendations

• ECCO Educational workshops on GL implementation: https://www.ecco-ibd.eu/education/educational-workshops.html

• ECCO pacient guidelines: https://www.ecco-ibd.eu/publications/ecco-efcca-patient-guidelines.html

• UEG Guideline Webinars: https://ueg.eu/education/online-education/webinars

• For further inspiration, check out these projects recently funded by UEG: https://ueg.eu/quality-of-care/projects/quality-of-care-initiatives

Figure 1.

Flowchart: the guideline implementation process.

Conclusion

This document can be used by clinicians, researchers, hospitals and clinical centers, research institutions, administrators and policy makers for easier GL implementation to assist local clinical and research decision making, educate local individuals or groups, assess and assure local quality of care, guide local allocation of resources and reduce the risk of legal liability for negligent care locally.

Acknowledgements

Thanks to all members of the UEG Quality of Care Task Force: Stavros Antoniou, Sorin Barbu, Doron Boltin, Markus Cornberg, Glen Doherty, Ian Gralnek, Thomas Gruenberger, Wafaa Khannoussi, Doenja Lambregts, Giovanni Marchegiani, Juan Mendive, Johann Ockenga, Jonas Rosendahl, Jordi Serra, Vita Skuja, Andreas Sturm, Riccardo Troncone and Carolynne Vaizey (https://ueg.eu/p/87) for their ideas, support and contribution to this document.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author received no financial support for the research, authorship and/or publication of this article.