Appendix 1
Recurring themes emerged during plenary discussions. The following list of strategies is organized according to those themes. Some strategies are listed under more than one theme.
Clinical realities (CR)
There is a need to focus on practical challenges related to implementation at the local level. This involves balancing evidence-based recommendations and clinical realities to ensure the credibility of the guidelines.
| 4.1. | Develop an information system that allows primary caregivers to use information practically, on a patient-specific basis. (National health organizations and governments) |
| 4.2. | Ensure access to materials, e.g., to public and patient education tools that are developed nationally and used locally. (National health organizations and governments) |
| 7.1. | Select a topic that is relevant. (in relation to producing a guideline that is likely to be adopted) (Provincial/territorial health organizations and governments) |
| 8.2. | Establish the use of CPGs (where applicable) as a regular part of practice. (Provincial/territorial health organizations and governments) |
| 8.3. | Promote the use of computer technology to facilitate access to information and promote utilization. (Provincial/territorial health organizations and governments) |
| 9.1. | Support mechanisms for regular review and identification of obsolete evidence. State the frequency of updating in the CPG. (in relation to staying current) (Provincial/territorial health organizations and governments) |
| 9.2. | Create flexible implementation strategies that can be adjusted with new evidence, e.g., through a computer network. (in relation to staying current) (Provincial/territorial health organizations and governments) |
| 13.2. | Develop, validate and communicate an accountability framework to clarify stakeholder roles and responsibilities. (in relation to achieving a balance regarding cost and quality, and professional autonomy) (Provincial/territorial health organizations and governments) |
| 15.1. | Involve local leaders in championing the CPG movement. (Regional health facilities and hospitals) |
| 15.2. | Involve skeptics in customizing CPGs for practice settings. (Regional health facilities and hospitals) |
| 15.3. | Accept that CPGs are dynamic, changing documents -- a consensus of best practice based on available evidence. Ensure a clear consensus among members of the development group, e.g., through a field trial. (Regional health facilities and hospitals) |
| 15.4. | State clearly when evidence is inadequate; do not try to make CPGs more than what they are (Regional health facilities and hospitals) |
| 15.5. | Establish an ongoing process (after the initial implementation) to look at best evidence and outcomes. (Regional health facilities and hospitals) |
| 15.6. | Ensure that the CPG can be applied in the clinical setting. (Regional health facilities and hospitals) |
| 23.1. | Find a good computer system that is patient-oriented and has user-friendly software for use during patient encounters, i.e., it must be quick, simple, concise, clear. To achieve this strategy, funding options must be developed and implemented, as well as specific actions for ensuring that health practitioners in medical clinics and offices will use the technology. (Medical clinics and offices) |
Public involvement (PI)
Participants recognized that the public is an important part of CPG implementation and should be involved in building ownership of CPGs in communities.
| 5.1. | Develop empowerment strategies that take into account the ethnic and cultural diversity of the public and health care practitioners. (National health organizations and governments) |
| 5.2. | Incorporate user-friendly language into public and patient information pieces related to CPG implementation. (National health organizations and governments) |
| 5.3. | Encourage use of the Internet. (National health organizations and governments) |
| 5.4. | Develop user-friendly public education initiatives. (National health organizations and governments) |
| 7.3. | Obtain public participation. (in relation to producing a guideline that is likely to be adopted) (Provincial/territorial health organizations and governments) |
| 8.1. | Ensure public support. (Provincial/territorial health organizations and governments) |
| 12.1. | Increase funding for consumer associations to provide information and counter false information, e.g., Consumer reports on health care issues. (Provincial/territorial health organizations and governments) |
| 12.2. | Develop strategies for addressing sensationalized media coverage related to the implementation of CPGs, e.g., by educating the media. (Provincial/territorial health organizations and governments) |
| 12.3. | Provide tear-off sections on CPGs for public and patient use. (Provincial/territorial health organizations and governments) |
| 12.4. | Advertise new CPG releases. (Provincial/territorial health organizations and governments) |
| 12.5. | Communicate with the public in appropriate language. (Provincial/territorial health organizations and governments) |
| 13.4. | Recognize that CPG development is part of CPG implementation, i.e., affirm the importance of building "ownership", the power of buy-in and the impact of political processes. (in relation to achieving a balance regarding cost and quality, and professional autonomy) (Provincial/territorial health organizations and governments) |
| 18.2. | Recycle savings earned through CPGs, e.g., assign a percentage of savings back to the program. (Regional health facilities and hospitals) |
| 19.1. | Develop and implement an outreach program. (Regional health facilities and hospitals) |
| 19.2. | Hold meetings to explain CPGs and enable buy-in by medical groups. (Regional health facilities and hospitals) |
| 19.3. | Use video conferencing. (Regional health facilities and hospitals) |
| 19.4. | Create computer linkages, e.g., CME, Internet at 2 levels -- health care practitioners and the public. (Regional health facilities and hospitals) |
| 19.5. | Create user-friendly public and patient information tools such as pamphlets and media coverage. (Regional health facilities and hospitals) |
| 19.6. | Encourage community identification with practitioners and institutions. (Regional health facilities and hospitals) |
| 19.7. | Provide the public with the information they need to determine whether the care they are getting is consistent with the best available evidence. (Regional health facilities and hospitals) |
| 23.1. | Educate the public. (Medical clinics and offices) |
| 23.2. | Produce clear and concise CPGs that are easily understood. (Medical clinics and offices) |
| 23.3. | Develop and stick with consistent messages. (Medical clinics and offices) |
| 25.1. | Place CPGs in the hands of the public to facilitate interaction with health care practitioners. (Educational institutions) |
| 25.2. | Provide consumer groups, e.g., advocacy and self-help groups, with CPGs and educate them regarding their benefits. (Educational institutions) |
| 25.3. | Provide information to the media in a standard format. (Educational institutions) |
| 27.2. | Create better ways to market CPGs, e.g., reminder systems, working with local leaders and groups, ensuring that tools are user friendly. (Research, industry and other settings) |
Coordination (CO)
There is a need for effective coordination among those involved in CPG development, dissemination and implementation, e.g., across various settings, governments, industries.
| 2.1. | Develop a national task force or assign a national organization(s) to be responsible for ensuring communication and coordination among groups that are developing CPGs. Identify roles and responsibilities of national, provincial and regional CPG developers to maximize expertise at various levels, promote collaboration and reduce inefficiency. (National health organizations and governments) |
| 2.2. | Establish a clearinghouse (registry) for CPGs.1 (National health organizations and governments) |
| 2.3. | Establish criteria for evaluating existing CPGs. (National health organizations and governments) |
| 2.4. | Use a multidisciplinary approach to prevent duplication of efforts. (National health organizations and governments) |
| 2.5. | Make information appropriate to public needs. (National health organizations and governments) |
| 3.4. | Establish links with Canadian Institute for Health Information (CIHI) for clinical indicators. (National health organizations and governments) |
| 7.7. | Use more collaborative efforts to avoid duplication and to translate evidence and adapt to individual settings. (in relation to producing a guideline that is likely to be adopted) (Provincial/territorial health organizations and governments) |
| 7.8. | Create a global multidisciplinary database such as CMA's CPG Infobase. (Provincial/territorial health organizations and governments) |
| 13.2. | Develop, validate and communicate an accountability framework to clarify stakeholder roles and responsibilities. (in relation to achieving a balance regarding cost and quality, and professional autonomy) (Provincial/territorial health organizations and governments) |
| 16.1. | Gain the commitment of senior organizational leaders, including the CEO. (Regional health facilities and hospitals) |
| 16.6. | Identify the potential for early success and reinforce these successes. (in relation to ensuring a receptive environment) (Regional health facilities and hospitals) |
| 17.1. | Incorporate all stages of the CPG development and dissemination process. (Regional health facilities and hospitals) |
| 17.2. | Ensure that committees and their mandates with respect to CPGs are clearly defined. (Regional health facilities and hospitals) |
| 17.3. | Develop a project plan or flow chart to integrate diverse elements, e.g., timelines and resources. (Regional health facilities and hospitals) |
| 17.4. | Coordinate groups working on guidelines within the facility. (Regional health facilities and hospitals) |
| 17.5. | Identify a leader to carry out the plan. (Regional health facilities and hospitals) |
| 17.6. | Define an accountability structure. (Regional health facilities and hospitals) |
| 17.7. | Establish linkages across the homehospital home continuum to ensure communication, understanding and acceptance.(Regional health facilities and hospitals) |
| 17.8. | Find the resources to pay for implementation. (Regional health facilities and hospitals) |
| 19.4. | Create computer linkages, e.g., CME, Internet at 2 levels -- health care practitioners and the public. (Regional health facilities and hospitals) |
| 27.1. | Re-align incentives for health care practitioners to encourage implementation of CPGs.2 (Research, industry and other settings) |
| 27.2. | Create better ways to market CPGs, e.g., reminder systems, working with local leaders and groups, ensuring that tools are user friendly. (Research, industry and other settings) |
| 27.3. | Create a national clearinghouse for CPGs, i.e., for evaluation, inventory and assistance with dissemination. (Research, industry and other settings) |
| 27.4. | Use existing practitioner networks, e.g., organized multidisciplinary networks of small groups, Internet discussion groups. (Research, industry and other settings) |
| 29.3. | Find and make use of resources available worldwide, e.g., knowledge and skills. (Research, industry and other settings) |
Education (ED)
Computer technology and the Internet were mentioned as important tools for education and for information systems and communication.
| 3.1. | Use a variety of process and outcome measurements, e.g., knowledge changes, behavioural changes, patient satisfaction measures. (National health organizations and governments) |
| 5.3. | Encourage use of the Internet. (National health organizations and governments) |
| 5.4. | Develop user-friendly public education initiatives. (National health organizations and governments) |
| 8.3. | Promote the use of computer technology to facilitate access to information and promote utilization. (Provincial/territorial health organizations and governments) |
| 8.4. | Encourage CME and other educational activities. (Provincial/territorial health organizations and governments) |
| 11.1. | Establish processes to identify new technologies and publish information about them immediately. (Provincial/territorial health organizations and governments) |
| 11.2. | Establish provincial/territorial registries of new technology as a resource for practitioners. (Provincial/territorial health organizations and governments) |
| 11.3. | Promote the discussion of CPGs through existing CME activities. (Provincial/territorial health organizations and governments) |
| 12.1. | Increase funding for consumer associations to provide information and counter false information, e.g., Consumer reports on health care issues. (Provincial/territorial health organizations and governments) |
| 12.2. | Develop strategies for addressing sensationalized media coverage related to the implementation of CPGs, e.g., by educating the media. (Provincial/territorial health organizations and governments) |
| 12.3. | Provide tear-off sections on CPGs for public and patient use. (Provincial/territorial health organizations and governments) |
| 12.4. | Advertise new CPG releases. (Provincial/territorial health organizations and governments) |
| 12.5. | Communicate with the public in appropriate language. (Provincial/territorial health organizations and governments) |
| 19.1. | Develop and implement an outreach program. (Regional health facilities and hospitals) |
| 19.2. | Hold meetings to explain CPGs and enable buy-in by medical groups. (Regional health facilities and hospitals) |
| 19.3. | Use video conferencing. (Regional health facilities and hospitals) |
| 19.4. | Create computer linkages, e.g., CME, Internet at 2 levels -- health care practitioners and the public. (Regional health facilities and hospitals) |
| 19.5. | Create user-friendly public and patient information tools such as pamphlets and media coverage. (Regional health facilities and hospitals) |
| 21.1. | Find a good computer system that is patient-oriented and has user-friendly software for use during patient encounters, i.e., it must be quick, simple, concise, clear. To achieve this strategy, funding options must be developed and implemented, as well as specific actions for ensuring that health practitioners in medical clinics and offices will use the technology. (Medical clinics and offices) |
| 23.1. | Educate the public. (Medical clinics and offices) |
| 23.4. | Develop CME programs with CPGs as core information. (Medical clinics and offices) |
| 23.5. | Educate health care practitioners about CPGs before the implementation phase. (Medical clinics and offices) |
| 24.1. | Address content issues (in relation to designing a consistent format for users):
a. Ensure that public- and patient-oriented documents contain a summary of the disease or issue; a summary of evidence; treatment choices; probable outcomes of the choices (i.e., if I choose "a" what can I expect?); sources of further information. b. Ensure that documents for health care practitioners contain a summary of evidence; strategies for prevention, diagnosis or care; methods; sponsorship; probable outcomes, including risk categories if applicable; source of CPG development; and availability of the full-text CPG. (Educational institutions) |
| 24.2. | Address format issues (in relation to designing a consistent format for users): create multiple media formats, i.e., electronic video, print, news; create multilingual formats; create multicultural formats. (Educational institutions) |
| 25.1. | Place CPGs in the hands of the public to facilitate interaction with health professionals. (Educational institutions) |
| 25.2. | Provide consumer groups, e.g., advocacy and self-help groups, with CPGs and educate them regarding their benefits. (Educational institutions) |
| 25.3. | Provide information to the media in a standard format. (Educational institutions) |
| 25.4. | Implement CPGs at a local level for physicians and other health care practitioners: use peer support groups; tie to training and certification processes; tie to CME credits. (Educational institutions) |
Evaluation and outcome measurement (EV)
Evaluation and outcome measurement are an essential component of the CPG process (Figure 1, page 2).
| 3.1. | Use a variety of process and outcome measurements, e.g., knowledge changes, behavioural changes, patient satisfaction measures. |
| 3.2. | Identify utilization data. (National health organizations and governments) |
| 3.3. | Measure public expectations, e.g., through focus group studies. (National health organizations and governments) |
| 3.4. | Establish links with Canadian Institute for Health Information (CIHI) for clinical indicators. (National health organizations and governments) |
| 8.5. | Be explicit about the strength of evidence or lack of evidence.3 (Provincial/territorial health organizations and governments) |
| 8.6. | Identify situations where interventional treatment is not effective, e.g., where palliative care is more appropriate. (Provincial/territorial health organizations and governments) |
| 14.1. | [Establish a working group to] Clarify stakeholder expectations at the beginning of the process; ensure that they are realistic, practical and linked to outcome measurement. (Provincial/territorial health organizations and governments) |
| 14.2. | [Establish a working group to] Define measurement outcomes at the beginning of the CPG development process. (Provincial/territorial health organizations and governments) |
| 14.3. | [Establish a working group to] Ensure, on an on-going basis, that comparison benchmarks are appropriate, relevant and accurate. (Provincial/territorial health organizations and governments) |
| 14.4. | [Establish a working group to] Clearly identify ownership of outcome information and how it will be used. (Provincial/territorial health organizations and governments) |
| 15.4. | State clearly when evidence is inadequate; do not try to make CPGs more than what they are. (Regional health facilities and hospitals) |
| 15.5. | Establish an ongoing process (after the initial implementation) to look at best evidence and outcomes (Regional health facilities and hospitals) |
| 20.1. | Devise measurements that are comprehensive and reflect the entire population cost, i.e., based on patient management across the continuum of care. (Regional health facilities and hospitals) |
| 20.2. | Identify outcome measures by consensus among the stakeholders. (Regional health facilities and hospitals) |
| 20.3. | Focus incentives on improving outcomes. (Regional health facilities and hospitals) |
| 20.4. | Identify valid, reliable tools for measuring outcomes. (Regional health facilities and hospitals) |
| 20.5. | Use clear, understandable language. (in relation to measuring outcomes that are valid and appropriate for all stakeholders) (Regional health facilities and hospitals) |
| 22.1. | Establish a multidisciplinary focus group to assess needs. (Medical clinics and offices) |
| 22.2. | Obtain feedback at CME courses, conferences, etc. (in relation to establishing the need for specific CPGs) (Medical clinics and offices) |
| 26.1. | For new CPGs, develop a variety of indicators from which users can choose to assess outcomes, e.g., build expectations and a satisfaction index into public-oriented products; health care practitioners can use indicators to monitor changes in their own practices; institutions can develop peer review processes such as infection rates and prescription use; regulatory bodies can use indicators for peer review purposes. (Educational institutions) |
| 28.1. | Set up systems to monitor changes made in health care as a result of CPGs; develop approaches to assess the impact of CPGs when outcome data are lacking. (Research, industry and other settings) |
| 28.2. | Develop indicators to monitor changes introduced by CPGs. (Research, industry and other settings) |
| 28.3. | Don't wait for the results of evaluation processes; continue with pilot studies and small projects; evolve gradually. (Research, industry and other settings) |
| 28.4. | Reinforce the need for evaluation; encourage government and other agencies to provide financial resources in this area. (Research, industry and other settings) |
Incentives for behaviour change (IC)
Participants emphasized the need for appropriate incentives to motivate behaviour change in practitioners.
| 3.1. | Use a variety of process and outcome measurements, e.g., knowledge changes, behavioural changes, patient satisfaction measures. (National health organizations and governments) |
| 7.4. | Obtain acceptance of users. (in relation to producing a guideline that is likely to be adopted) (Provincial/territorial health organizations and governments) |
| 7.5. | Involve CME providers. (in relation to producing a guideline that is likely to be adopted) (Provincial/territorial health organizations and governments) |
| 7.6. | Obtain support of licensing or professional bodies.(in relation to producing a guideline that is likely to be adopted) (Provincial/territorial health organizations and governments) |
| 13.3. | Develop and implement a communication strategy that identifies the purpose, stakeholders, a process for evidence-based medicine and an iterative approach. (in relation to achieving a balance regarding cost and quality, and professional autonomy) (Provincial/territorial health organizations and governments) |
| 13.4. | Recognize that CPG development is part of CPG implementation, i.e., affirm the importance of building "ownership", the power of buy-in and the impact of political processes. (in relation to achieving a balance regarding cost and quality, and professional autonomy) (Provincial/territorial health organizations and governments) |
| 16.5. | Create and communicate incentives. (in relation to ensuring a receptive environment) (Regional health facilities and hospitals) |
| 18.1. | Establish the return on investment for CPGs, e.g., improved quality, cost analysis. (Regional health facilities and hospitals) |
| 18.2. | Recycle savings earned through CPGs, e.g., assign a percentage of savings back to the program. (Regional health facilities and hospitals) |
| 18.3. | State clearly principles, goals and follow-through mechanisms. (in relation to the challenge of aligning incentives for stakeholders) (Regional health facilities and hospitals) |
| 18.5. | Look at all types of incentives e.g., improved patient care. (in relation to the challenge of aligning incentives for stakeholders) (Regional health facilities and hospitals) |
Multidisciplinary collaboration (MC)
Multidisciplinary collaboration (i.e., broad representation in the health care field) is essential within and among individuals and groups focused on the implementation of CPGs. Benefits include broader ownership and adoption of the CPGs as well as improved understanding and the reconciliation of conflicting objectives among various stakeholders.
| 2.4. | Use a multidisciplinary approach to prevent duplication of efforts. (National health organizations and governments) |
| 6.1. | Recognize that reconciling conflicting objectives is a problem. [in relation to various stakeholders] (Provincial/territorial health organizations and governments) |
| 6.2. | Identify, analyse and understand conflicting objectives. [in relation to various stakeholders] (Provincial/territorial health organizations and governments) |
| 6.3. | Come to agreement among stakeholders about managing and resolving conflicts. (Provincial/territorial health organizations and governments) |
| 6.4. | Communicate/implement previous strategies with stakeholders. (Provincial/territorial health organizations and governments) |
| 7.2. | Ensure multidisciplinary involvement. (in relation to producing a guideline that is likely to be adopted)(Provincial/territorial health organizations and governments) |
| 7.7. | Use more collaborative efforts to avoid duplication and to translate evidence and adapt to individual settings. (in relation to producing a guideline that is likely to be adopted) (Provincial/territorial health organizations and governments) |
| 7.8. | Create a global multidisciplinary database such as CMA's CPG Infobase. (in relation to producing a guideline that is likely to be adopted) (Provincial/territorial health organizations and governments) |
| 13.1. | Recognize stakeholders' interests explicitly and define areas of common interest. (in relation to achieving a balance regarding cost and quality, and professional autonomy) (Provincial/territorial health organizations and governments) |
| 14.4. | Clearly identify ownership of outcome information and how it will be used. (Provincial/territorial health organizations and governments) |
| 15.3. | Accept that CPGs are dynamic, changing documents -- a consensus of best practice based on available evidence. Ensure a clear consensus among members of the development group, e.g., through a field trial. (Regional health facilities and hospitals) |
| 16.3. | Develop a critical mass of supporters. (in relation to ensuring a receptive environment) (Regional health facilities and hospitals) |
| 16.4. | Establish trust. (in relation to ensuring a receptive environment) (Regional health facilities and hospitals) |
| 20.2. | Identify outcome measures by consensus among the stakeholders. (Regional health facilities and hospitals) |
| 22.1. | Establish a multidisciplinary focus group to assess needs. (Medical clinics and offices) |
| 29.1. | Use multidisciplinary working groups including various health care practitioners, e.g., nurses, physiotherapists, occupational therapists, nutritionists, etc.; include the public and industry; involve busy family physicians and others who may not be interested in CPGs or may perceive them as irrelevant; involve pharmacists in guidelines related to drug therapy. (Research, industry and other settings) |
| 29.2. | Change the notion in some physicians' minds that only they can do this work. (Research, industry and other settings) |
| 29.3. | Find and make use of resources available worldwide, e.g., knowledge and skills (Research, industry and other settings) |
Resources (RE)
As in most workshops focused on change, the challenge of finding resources to implement suggested strategies was a common subject. Participants recognized the importance of demonstrating the cost effectiveness of CPGs as a key element in finding or justifying resources for implementation.
| 1.1. | Identify and coordinate existing resources. (National health organizations and governments) |
| 1.2. | Identify other possible funding sources. (National health organizations and governments) |
| 1.3. | Enter into partnerships with other groups such as industry and foundations; create guidelines for how to do this. (National health organizations and governments) |
| 1.4. | Lobby for funding. (National health organizations and governments) |
| 10.1. | Convince government and industry that this is an important activity requiring stable funding. (Provincial/territorial health organizations and governments) |
| 10.2. | Recycle savings into further strategies. (Provincial/ territorial health organizations and governments) |
| 10.3. | Develop information systems to capture quality indicators and outcomes concurrently with interventions. (Provincial/territorial health organizations and governments) |
| 16.2. | Ensure availability of resources -- time, people and a priority ranking. (Regional health facilities and hospitals) |
| 17.8. | Find the resources to pay for implementation. (Regional health facilities and hospitals) |
| 18.1. | Establish the return on investment for CPGs, e.g., improved quality, cost analysis. (Regional health facilities and hospitals) |
| 18.2. | Recycle savings earned through CPGs, e.g., assign a percentage of savings back to the program. (Regional health facilities and hospitals) |
| 18.3. | State clearly principles, goals and follow-through mechanisms.(in relation to the challenge of aligning incentives for stakeholders) (Regional health facilities and hospitals) |
| 18.4. | Establish a risk (investment) capital fund to support CPG development and implementation. (Regional health facilities and hospitals) |
| 18.5. | Look at all types of incentives e.g., improved patient care. (in relation to the challenge of aligning incentives for stakeholders) (Regional health facilities and hospitals) |
| 18.6. | Find and commit resources to pay for implementation. (Regional health facilities and hospitals) |
| 21.1. | Find a good computer system that is patient-oriented and has user-friendly software for use during patient encounters, i.e., it must be quick, simple, concise, clear. To achieve this strategy, funding options must be developed and implemented, as well as specific actions for ensuring that health practitioners in medical clinics and offices will use the technology. (Medical clinics and offices) |
| 29.3. | Find and make use of resources available worldwide, e.g., knowledge and skills. (Research, industry and other settings) |
1 The CMA is currently involved in collecting information on guidelines that have been developed by national and provincial expert groups in Canada. (See A national CPG database.)
2 This discussion was broad based. A concern was expressed that this strategy might be interpreted as being financial only, which is not the case.
3 Where evidence is lacking, those involved should indicate the need for research to provide that knowledge (see Guidelines for Canadian clinical practice guidelines1).
