Implementing best practice guidelines: The RNAO Toolkit

Registered Nurses' Association of Ontario (2002)
Toronto, ON

How to cite this summary:

National Collaborating Centre for Methods and Tools (2011). Implementing best practice guidelines: The RNAO Toolkit. Hamilton, ON: McMaster University. Retrieved from http://www.nccmt.ca/registry/view/eng/89.html.

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Keywords : Implement, Evaluate, Program planning, Capacity (individual, organizational, system)

Tool Knowledge Knowledge Planning Doing Evaluating

These summaries are written by the NCCMT to condense and to provide an overview of the resources listed in the Registry of Methods and Tools and to give suggestions for their use in a public health context. For more information on individual methods and tools included in the review, please consult the authors/developers of the original resources.

Relevance for Public Health
 The RNAO Toolkit: Implementation of clinical practice guidelines is relevant for public health settings. The tool identifies and assesses stakeholder and organizational readiness, and can help users develop an implementation plan for public health guidance or innovative programs. For instance, educational sessions can inform and help frontline practitioners to implement a new immunization protocol or smoking cessation program.
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?
Evaluation and Measurement Characteristics
Evaluation
 Has been evaluatedHas been evaluated. 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.
Validity
 Not applicable
Reliability
 Not applicable
Methodological Rating
 Not applicableNot applicable
Implementing the Method/Tool
Who is involved
 Individuals at all levels within public health units would be involved in using this tool to facilitate implementation of a new program or guideline. Various roles may be involved with developing the implementation plan, with support from frontline practitioners to implement and evaluate the implementation plan.
Time
 Information not available
Additional Resources and/or Skills Needed for Implementation
 Using this toolkit requires expertise in these areas: project management, communications, budgeting and evaluation. Also, knowledge of resources and stakeholders, including being able to access local champions, is critical to garner support for the new program.
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: 
              - structure (decision-making, infrastructure, physical facilities)
              - workplace culture
              - communication
              - leadership
              - knowledge, skills and attitudes of target groups
              - commitment to quality management
              - resource availability
              - 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.
Conditions for Use
 Not specified
Method/Tool Development
Developer(s)
 Toolkit Development Panel:
Alba DiCenso, RN, PhD (Chair)
Irmajean Bajnok, RN, PhD
Elizabeth Borycki, RN, MN
Barbara Davies, RN, PhD
Ian Graham, PhD
Margaret Harrison, RN, PhD
Jo Logan, RN, PhD
Lynn McCleary, RN, PhD
Michael Power, BA, MIM
Julia Scott, RN, MBA

Toolkit Development Support Team:
Tazim Virani, RN, MScN
Anne Tait, RN, BScN
Heather McConnell, RN, BScN, MA(Ed)
Carrie Scott
Elaine Gergolas, BA

Registered Nurses' Association of Ontario
Nursing Best Practice Guidelines Program
158 Pearl St
Toronto ON M5H 1L3
www.rnao.org
Method of Development
 The RNAO Toolkit: Implementation of clinical practice guidelines was developed to accompany the Nursing Best Practice Guidelines (NBPG) Project funded by the Ontario Ministry of Health and Long-Term Care. The aim of the NBPG Project was to develop, pilot, evaluate and disseminate nursing best practice guidelines. A panel of nurses/researchers developed the Toolkit  to help organizations implement clinical practice guidelines.
Release Date
 2002
Contact Person/Source
 Alba DiCenso, BScN, MSc, PhD
CHSRF/CIHR Chair in Advanced Practice Nursing
Professor, School of Nursing
Joint Member, Dept of Clinical Epidemiology & Biostatistics
Director, Ontario Training Centre for Health Services and Policy Research

McMaster University Faculty of Health Sciences
1200 Main Street West, Rm. 3N25B
Hamilton, ON
Canada L8N 3Z5
tel: 905.525.9140 x 22277
fax: 905.524.5199
email: dicensoa@mcmaster.ca

Resources

Title of Primary Resource
 Toolkit: Implementation of clinical practice guidelines
File Attachment
 None
Web-link
 http://old.rnao.ca/Page.asp?PageID=924&ContentID=823
Reference
 Registered Nurses' Association of Ontario. (2002). Toolkit: Implementation of clinical practice guidelines. Toronto, Canada: Registered Nurses' Association of Ontario. Retrieved from: http://old.rnao.ca/Page.asp?PageID=924&ContentID=823
Type of Material
 Toolkit
Format
 On-line Access
Cost to Access
  
Language
 English, French
Conditions for Use
  

Title of Supplementary Resource
 A toolkit to facilitate the implementation of clinical practice guidelines in healthcare settings.
File Attachment
 None
Web-link
 http://www.longwoods.com/content/16515
Reference
 DiCenso, A., Virani, T., Bajnok, I., Borycki, E., Davies, B., Graham, I., Harrison, M., et al. (2002). A toolkit to facilitate implementation of clinical practice guidelines in healthcare settings. Hospital Quarterly, 5 (3), 55-60.
Type of Material
 Journal article
Format
 Periodical
Cost to Access
 Journal article purchase 
Language
 English
Conditions for Use
 Copyright © 2002 Longwoods Publishing Corp. 

Title of Supplementary Resource
 Changing nursing practice: Evaluating the usefulness of a best-practice guideline implementation toolkit
File Attachment
 None
Web-link
 http://www.longwoods.com/content/17034
Reference
 Dobbins, M., Davies, B., Danesco, E., Edwards, N., & Virani, T. (2005). Changing nursing practice: Evaluating the usefulness of a best-practice guideline implementation toolkit. Nursing Leadership, 18 (1), 34-45.
Type of Material
 Journal article
Format
 Periodical
Cost to Access
 Journal article purchase 
Language
 English
Conditions for Use
 Copyright © 2005 Longwoods Publishing Corp.