Implementing best practice guidelines: The RNAO Toolkit

Description

The Registered Nurses' Association of Ontario (RNAO) developed this resource to help organizations implement best practice guidelines to improve practice and health outcomes. The RNAO Toolkit: Implementation of clinical practice guidelines provides a six-step process to assess, prepare and use dissemination strategies that fit the organization.

Clinical practice guidelines (CPGs) are "systematically developed statements of recommended best practice in a specific clincial area, designed to provide direction to practitioners in their practice" (p. 5).

The goals of the RNAO Toolkit are to help those responsible for implementing practice guidelines to:

• identify a high quality practice guideline;
• gain support of key stakeholders and champions;
• assess organizational support and readiness to adopt the guideline;
• use effective support and readiness to adopt the guideline;
• use effective strategies to implement the practice guideline; and,
• evaluate practice guideline implementation.

The RNAO Toolkit: Implementation of clinical practice guidelines is based on findings from the literature:

• Users need to critically appraise clinical practice guidelines to identify those that are of good quality to implement in their practice setting.
• The process of implementing a change in clinical practice is similar to organizational change processes.
• Models for research use draw on theories such as change theory and diffusion of innovation theory. No single model for research use has been adequately validated through research.
• To bring about a change in practice, multiple implementation strategies targeted to specific barriers and facilitators are more likely to be effective than a single implementation strategy.

The Toolkit is based on a conceptual model with six steps. Each step includes key definitions, templates and worksheets, stakeholder and resource implications, a case example and additional reading.

• Step 1: Selecting Your Clinical Practice Guideline
• Step 2: Identifying, Analyzing and Engaging Your Stakeholders
• Step 3: Assessing Your Environmental Readiness
• Step 4: Deciding on Your Implementation Strategies
• Step 5: Evaluating Your Success
• Step 6: What About Your Resources?

Steps for Using Method/Tool

The RNAO Toolkit: Implementation of clinical practice guidelines consists of six steps:

Step 1: Selecting Your Clinical Practice Guideline (CPG)

• With the increasing number of best practice guidelines, there is a need to select high quality guidelines.
• To critically appraise a CPG, use the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument, a rigorously tested tool to appraise CPG.
• Use the Action Plan Template (accessed from RNAO website, along with other worksheets).
• Identify the recommendations for implementation.

Step 2: Identifying, Analyzing and Engaging Your Stakeholders

• Examine the role of stakeholders who may have an interest in the decision to implement best practice guidelines.
• This involves identifying stakeholders, analyzing their interests, determining their level of support and influence related to implementation and developing approaches to engage key stakeholders for effective implementation.
• Engaging stakeholders early in the process acknowledges and ensures their involvement and provides transparency in the implementation process.
• Use the Stakeholder Assessment Worksheet to collect this information.

Step 3: Assessing Your Environmental Readiness

• Assess organizational readiness and develop a plan for effective implementation.
• Eight elements support implementation of best practice guidelines:

1. structure (decision-making, infrastructure, physical facilities)
2. workplace culture
3. communication
4. leadership
5. knowledge, skills and attitudes of target groups
6. commitment to quality management
7. resource availability
8. interdisciplinary relationships

• Use the Environment Readiness Assessment Worksheet to identify facilitators and barriers within these eight elements.

Step 4: Deciding on Your Implementation

• This step summarizes what is known about the effectiveness of various strategies for implementing practice guidelines.
• The Toolkit includes a list of potential strategies, grouping strategies as generally effective, sometimes effective or of little or no effect in clinical settings.
• Examples of implementation strategies include interactive educational sessions, audit and feedback, local opinion leaders and local consensus building.
• Specific steps include:
  1. Use data from the environmental assessment and stakeholder analysis to identify barriers and facilitators.
  2. Enlist local champions and those with authority to provide support.
  3. Consider strategies for the setting that have shown some effectiveness.
  4. Select implementation strategies that build on available resources and supports.
  5. Select a starting point with a high chance of success to pilot implementation.
  6. Be flexible in adjusting implementation strategies to the practice reality by involving local stakeholders.
  7. Provide ongoing monitoring and support to help users with learning.

Step 5: Evaluating Your Success

• Consider collecting baseline data before beginning to use the implementation strategies.
• Develop a comprehensive evaluation of the implementation plan with respect to structure, process and outcome evaluations (see definitions on p. 58).
• Use the table on p. 63 to outline evaluation measures.
• Specific steps include:
  1. Identify expert resources to help with the evaluation.
  2. Design an evaluation plan that outlines implementation goals; target groups; structure, process and outcome measures; and resources required.
  3. Consider issues related to data collection (such as the structure, process or outcome measures to collect).
  4. Develop a timeline for the evaluation.
  5. Seek approval from appropriate bodies (administration, research ethics board, community representative groups).
  6. Prepare a budget that includes costs of evaluation (include in Budget Worksheet).

Step 6: What About Your Resources?

• In this last step, identify all resources needed for implementation and prepare an implementation budget (use Budget Worksheet).
• Examine human, physical and financial resources necessary at each step in the implementation process.
• Develop a budget that allocates resources to the 4 Ps (product, price, place and promotion).
• Strategies to garner resources for implementation include:
  1. Create a campaign strategy for the implementation plan.
  2. Generate a plan to attract resources/use local champions.
  3. Pool resources/build partnerships with key allies.

Evaluation

An evaluation of the RNAO Toolkit was conducted via a mailed questionnaire to clinical resource nurses and steering committee members involved in implementing best practice guidelines (Dobbins et al., 2005). Of 61 possible participants, 41 (68%) returned the questionnaire. Most respondents used the Toolkit primarily to identify, analyze and engage stakeholders, and to assess environmental readiness. Twenty-three respondents indicated they used the Toolkit to plan their implementation strategy.