[ 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).