[ 238 ]
International Journal of
Health Care Quality
Assurance
11/ 7 [ 1998] 238–243
© MCB University Press
[ ISSN 0952-6862]
Planned and reported implementation of clinical
practice guidelines
Andrew Millard
Scottish Clinical Audit Resource Centre, Departments of Postgraduate Medical
Education and Public Health, University of Glasgow, Scotland
The aim of this project was to
compare the intentions with
reported action of health
Trusts in Scotland to priori-
tise and implement published
SIGN clinical guidelines. All
health Trusts in Scotland
were asked about plans for
implementation, and resur-
veyed 15-18 months later for
confirmation. Specific guide-
line implementation groups
led by medical doctors were
the most common implemen-
tation structure. Implementa-
tion usually consisted of
baseline audit, development
of a local version, and reau-
dit. In one case a successful
link between acute and pri-
mary care through an area
level GP audit facilitator was
thought to increase imple-
mentation. More research is
required to: find out what
influences the ability of an
organisation to implement
guidelines; identify particular
facilitating factors or barri-
ers; and on factors influenc-
ing the ability of a health
organisation to implement
guidelines.
International Journal of
Health Care Quality
Assurance
11/ 7 [ 1998] 238–243
© MCB University Press
[ ISSN 0952-6862]
Aims
The project aimed to discover the proportion
implemented of planned guideline implemen-
tation projects and to compare this in com-
munity and acute Trusts. It aimed to find out
what was being done as implementation;
hence implementation was not predefined. It
aimed also to identify the priority setting
methods used to choose which guidelines to
implement.
Background
The Scottish Intercollegiate Guidelines Net-
work (SIGN) was developed following a report
to the National Health Service (NHS) in Scot-
land (McLean, 1993) which:
commended the development of national
guidelines – broad statements which relate
to an optimal level of care in which current
knowledge and experience are balanced
against the constraints of available staff and
other resources (Petrie et al., 1995).
The main SIGN committee represents clini-
cal specialties and professions through Scot-
land. There are about 30 members of this
group, which meets three times a year to
consider proposals for topics for new guide-
lines. Topics are submitted on a form asking
for a description of the problem and for
details of existing evidence about it. The
forms are peer reviewed by specialist review-
ers before consideration by the committee. In
choosing topics the committee take into
account the burden of disease, the potential
for improvement, and the existence of other
guidelines in the same area. Topics must be
multidisciplinary. SIGN working groups
research and write guidelines on clinical
topics. They are led by Fellows of the Scottish
Royal Colleges and Societies. A decision is
made with the proposer about who should
chair the working group. Members are
invited, trained in critical appraisal, the
remit is defined, and a literature search is
carried out by a qualified librarian. Studies
are selected for review according to agreed
criteria. Their methodology is evaluated and
an evidence grading is given. The evidence is
then synthesised and interpreted and draft
recommendations are produced. The draft
guideline is presented at an national open
meeting, comments assessed, and the final
draft is reviewed by the SIGN editorial board.
The guidelines are published free to health
service organisations in Scotland (Harlen,
1998).
The SIGN guideline programme currently
plans 45 guidelines by early 1999 of which 21
were published by March 1998.
Clinical guidelines are a central component
of the clinical effectiveness initiative in the
Scottish health service (Scottish Office, 1997).
This charges health boards to consult with
Trusts in creating health improvement pro-
grammes. These programmes must set out “a
rolling programme for the implementation of
evidence-based clinical guidelines and clini-
cally effective practice, to be monitored
through clinical audit”.
Over the past few years, clinical practice
guidelines have been applied in various
forms as a solution to not just one but a set of
interlinked problems facing health services
all over the world.
They have been suggested as a way of more
objectively monitoring and measuring perfor-
mance. There is evidence of a discrepancy
between what clinicians perceive they do and
what they actually find when they audit their
medical records (Ellis et al. , 1991; Oxm an et
al. , 1994). This may not be adequately
addressed by peer review since a review of
peer assessment without guidelines
concludes that this is unreliable (Goldman,
1992). The most objective measure, compari-
son of outcomes, is as yet too complex for
routine use in measuring performance
(Davies and Crombie, 1997; Orchard, 1994).
However, evidence-based guidelines allow a
meaningful and important comparison of
process.
Guidelines are also suggested as a way of
improving clinical practice by increasing
communication (Wray and Maresh, 1997) and
as useful in teamworking (McNicol et al. ,
1993). They are also a tool for getting research
into practice (Haines, 1997).
More controversially, legally enforceable
clinical practice guidelines are used in
France as a means of saving money (Durande-
Zaleski et al. , 1997).