Successes and Failures in the Implementation of Evidence-Based Guidelines for Clinical Practice
Successes and Failures in the Implementation of Evidence-Based Guidelines for Clinical Practice
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DOI：
10.1097/00005650-200108002-00003
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发表时间：
2001-08
期刊：
影响因子：
3
通讯作者：
R. Grol
中科院分区：
文献类型：
--
作者：
R. Grol
背景。（循证）临床实践指南的制定和实施是提高护理质量的有前途和有效的工具之一。然而，许多指南在传播后并没有被使用。实施活动通常只产生适度的改进。详细研究具体的指导方案，吸取其成功经验和失败经验是十分重要的。目标。本文介绍了荷兰10多年来发展和传播家庭医学临床指南的经验。结果。在严格的程序中制定了70多条循证指南，并通过各种策略进行传播。目标人群对指南的了解和接受程度很高。特别是，书面（科学期刊、支助材料）和个人方法（当地协商一致讨论、与同事接触、同行外联访问）的多方面方法似乎在传播方面是有效的。平均67%的决定遵循指南的建议，但不同的医生和不同的指南之间存在很大差异。需要制定具体战略来处理执行过程中可能遇到的障碍，以提高遵守情况。具体的执行项目显示了在开始执行之前对目标群体和目标设定进行“诊断分析”的重要性。结论。实施指南的程序应该经过良好的设计、充分的准备，最好在使用前进行试点测试。这种方案应纳入改善护理的正常渠道和结构。需要对实施细节进行更多的研究，以便更好地了解实践中变化的关键决定因素。
Background.The development and implementation of (evidence-based) clinical practice guidelines is one of the promising and effective tools for improving the quality of care. However, many guidelines are not used after dissemination. Implementation activities frequently produce only moderate improvement. It is important to study specific guideline programs in detail to learn from their successes and failures. Objectives.Experiences with more than 10 years of development and dissemination of clinical guidelines for family medicine in the Netherlands are presented in this paper. Results.More than 70 evidence-based guidelines have been set in a rigorous procedure and have been spread via a variety of strategies. Knowledge and acceptance of the guidelines in the target group is high. In particular, a multifaceted approach with written (scientific journal, support materials) and personal approaches (local consensus discussions, contact with colleagues, outreach visits by peers) seems to be effective in the dissemination. The guideline recommendations are followed in on average 67% of the decisions, but there is a large variation between different physicians and between different guidelines. Specific strategies designed to handle possible obstacles to implementation are needed to improve adherence. Specific implementation projects showed the importance of a “diagnostic analysis” of the target group and target setting before the start of the implementation. Conclusions.A program to implement a guideline should be well designed, well prepared, and preferably pilot tested before use. Such a program should be built into the normal channels and structures for improving care. More research into the details of implementation is needed to better understand the critical determinants of change in practice.