Guideline dissemination through integrated care networks: Lessons from Ontario's best practice guidelines for stroke care
Susan Rappolt, PhD, OT Reg. (Ont.), Knowledge Translation Program, University of Toronto
Joanne Goldman, MSc, Knowledge Translation Program, University of Toronto
Dave Davis, MD, FCFP, Knowledge Translation Program, University of Toronto
As part of the Ontario Stroke Strategy, regional stroke coordinators were employed to disseminate best practice guidelines for stroke care to a province-wide network of service delivery organizations. In an evaluation of the effectiveness of the guideline dissemination strategy, researchers from the University of Toronto's Knowledge Translation Program identified a number of critical factors for success, including sufficient personnel, financial support for clinicians, local stroke champions and a supportive organizational climate. These and other lessons may guide provincial and national efforts to develop and promote best practice guidelines for integrated care.
The Ontario Stroke Strategy (OSS) aims to decrease the number of strokes and improve the care of people with strokes, through the creation of a province-wide, integrated, and comprehensive system of stroke care. The OSS led to the creation of regional and district stroke centres across the province as sites of expertise and leadership, the hiring of regional and district stroke coordinators to support and implement the OSS and the development and dissemination of nineteen best practice guidelines for stroke care.
The guidelines, published in 2003, were developed through a partnership between the Heart and Stroke Foundation of Ontario (HSFO) and the regional stroke centres. They address all levels of stroke care including: stroke prevention and recognition; pre-hospital, emergency, and acute care; transition management; rehabilitation; and community re-engagement. Stroke coordinators, including education coordinators, became champions of the best practice guidelines and were responsible for their dissemination to all health care providers and stakeholders engaged in the continuum of stroke care in their jurisdictions.
While research findings were used to both develop the guidelines and design strategies for their dissemination, the effectiveness of guideline dissemination across integrated networks of care has not previously been studied. In June 2004, HSFO contracted us, as researchers from the Knowledge Translation Program at the University of Toronto, to examine the process of guideline dissemination and, in particular, the stroke coordinators' experiences and their perceptions of the effectiveness of the HSFO guideline dissemination strategy.
The KT initiative
The guidelines were formally launched by the HSFO through a dissemination workshop in Toronto in June 2004. The workshop was designed to facilitate understanding of the guidelines and to model dissemination methods for stroke coordinators, who would tailor them to particular needs in their jurisdictions. To assist local dissemination and uptake, HSFO developed printed and electronic versions of the guidelines, a video, a slide presentation, posters, pamphlets, evidence-based summaries, and other materials.
We distributed surveys to the stroke coordinators who participated in the workshop, and conducted follow-up in-depth telephone interviews approximately one month after dissemination of the guidelines into their local jurisdictions. The interviews focused on the stroke coordinators' local dissemination strategies, their perceptions of the effectiveness of the dissemination of the guidelines in influencing the practices of health care professionals in their jurisdictions and their overall perspectives on HSFO's dissemination process.
Results of the KT initiative
Half of the 38 workshop participants returned surveys and 18 telephone interviews were conducted. Some coordinators had been involved in the development of the guidelines, while others were new in their positions and first learned about the guidelines at the workshop.
We identified a number of goals and processes that were common across the stroke coordinators' local dissemination strategies. These included:
- Investing time in developing relationships with administrators, managers, and front line practitioners to secure their buy-in and set the stage for future changes;
- Conducting needs assessments, both formal and informal, to identify the gaps and needs of various stakeholders;
- Increasing awareness and knowledge of the guidelines by organizing lectures, workshops, and promoting HSFO educational resources such as pamphlets, posters and online learning modules; and
- Promoting practice changes through strengthening collaborations, supporting progress, and providing tools, such as assessments and checklists, to carry out the guidelines.
The formal and informal communication between the stroke network and education coordinators across the province, was instrumental to guideline dissemination activities.
The coordinators also identified factors that they perceived to be critical to the promotion and implementation of the guidelines:
- Funded personnel, including their own positions as regional and district stroke coordinators and regional education coordinators, and administrative support and education facilitators, were instrumental to guideline dissemination given the extensive time and effort required to plan, organize, implement, and follow-up. Staffing levels of stroke programs must also be sufficient for front line practitioners to implement the guidelines.
- Local stroke champions were seen as strategically placed people with a concern about stroke care and decision-making capabilities that could generate buy-in from their organizations and provide venues for changes. Local stroke champions were valuable members of stroke committees.
- A critical mass of human and administrative resources supported optimal stroke care. Those organizations perceived to have the least difficulty implementing the guidelines were those with a broad range of stroke services, strong administrative and physician support, clinicians who were already committed to best practice, and dedicated and effective stroke champions. Coordinators located in rural areas or smaller community hospitals faced the challenge of applying the guidelines in contexts where there are not large concentrations of stroke patients or professionals with expertise in stroke care.
- The Ontario Stroke Network, or more specifically, the formal and informal communication between the stroke network and education coordinators across the province, was seen as instrumental to guideline dissemination activities. Members of the network shared resources and frequently consulted each other.
While the coordinators felt that there were positive outcomes from their dissemination and promotion of the uptake of the guidelines, the following issues were identified as impeding their efforts:
Our findings also highlighted the incapacity of health service providers to comply with the guidelines when working within organizations that did not support their learning and practice changes.
- Organizational barriers included insufficient commitment from senior administration, staff turnover and shortages, work overload, lack of financial support for employee training and lack of dedicated time to make and sustain practice changes. These were particular concerns of coordinators who worked in jurisdictions with few or widely dispersed stroke patients and experts, and in rehabilitation programs, long-term care, and Community Care Access Centres.
- Geographical and organizational reach. The coordinators described significant challenges in reaching all stakeholders, due to large geographical areas and the number of stakeholders involved.
- Evaluation processes and tools. Many coordinators were concerned there had been insufficient emphasis placed on the measurement of outcomes resulting from the dissemination of the guidelines. Some indicated that patient outcome data would promote stakeholder buy-in, particularly by physicians and administration, and provide direction for future interventions.
- Resistance to change. Some coordinators saw the lack of a mandated organizational commitment to the overall OSS as a barrier to the promotion of the guidelines. There were also instances of resistance to change because of disagreements about the evidence. Some viewed strained relations between provider organizations and employed professionals, and general feelings of being overwhelmed by changes in health care, as underlying causes of resistance to uptake and implementation of the guidelines.
The strengths and weaknesses of the guideline dissemination strategy provide insight into methods for translating clinical evidence into practice with different targets, settings and organizational structures, as well as across interorganizational management structures.
Our evaluation suggests that the methods used to disseminate the guidelines were consistent with available research evidence in knowledge translation (KT). The coordinators met face-to-face with key stakeholders to introduce the guidelines, negotiate their meaning and implications for particular professions and organizations, and to encourage buy-in and support.1 They then adapted dissemination strategies and educational interventions to identified needs and contexts.2 The coordinators also cultivated local champions and opinion leaders to optimize guideline uptake and practice change, although questions about the roles of opinions leaders in KT are unresolved in the research literature.3,4 Our findings also highlighted the incapacity of health service providers to comply with the guidelines when working within organizations that did not support their learning and practice changes, as well as the challenges of overcoming conflicting opinions about the evidence and a general resistance to change.5,6
Greater emphasis should be placed on engaging organizational decision makers in guideline development, dissemination, implementation and evaluation.
The strengths and weaknesses of the guideline dissemination strategy provide insight into methods for translating clinical evidence into practice with different targets, settings and organizational structures, as well as across inter-organizational management structures. We hope that they may guide other provincial and national efforts to develop and promote best practice guidelines for integrated care.
- Sufficient complements of clinical, educational and administrative personnel, as well as financial support for clinicians' continued education, are necessary for guidelines to be learned, adopted and implemented into health care providers' clinical practices.
- Comprehensive strategies to evaluate the effectiveness of guideline dissemination are needed. While this study focused on participants' evaluations of the effectiveness of the dissemination process, objective measures of changes in provider behaviours and patient outcomes are also required.
- Alternative methods may be needed to promote guidelines for continuing care and to engage Community Care Access Centres and long-term care facilities in guideline adoption and implementation.
- Additional supports may be needed to reach rural and remote regions, and community hospitals.
- Greater emphasis should be placed on engaging organizational decision makers in guideline development, dissemination, implementation and evaluation to ensure that sufficient human and material resources are in place to support positive practice changes and improved patient outcomes.
Conclusions and implications
HSFO is involved in ongoing guideline implementation and evaluation initiatives, building upon the findings from this and other studies. For example, the guidelines have been integrated into the Multidisciplinary Learning Objectives for Stroke, which identify knowledge, skills, and values for health professionals working with stroke survivors across the continuum. A pilot project is underway to develop a guide on proven strategies for implementing the objectives across varied clinical settings. Recent developments for a Canadian Stroke Strategy (CSS) have prompted a National Best Practices, Standards and Guidelines Working Group, as well as a National Evaluation Strategy. Evaluations of the OSS and CSS will involve ongoing measuring and monitoring of performance indicators that reflect quality of care provided and/or patient outcomes identified in best practice guidelines.
We wish to acknowledge Mary Lewis and Sandra Zambon from the Heart and Stroke Foundation of Ontario for their support with this case study.
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2 Grol R., and J. Grimshaw. 2003. From best evidence to best practice: Effective implementation of change in patients' care. Lancet 362 (9391): 1225-30.
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5 Cabana M. D., C. S. Rand, N. R. Powe, A. W. Wu, M. H. Wilson, P. A. Abboud, and H. R. Rubin. 1999. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 282 (15): 1458-65.
6 Ferlie E. B., and S. M. Shortell. 2001. Improving the quality of health care in the United Kingdom and the United States: A framework for change. Milbank Q 79 (2): 281-315.
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