3. Addressing challenges

The challenges involved in implementing CPGs are complex and vary from setting to setting. Workshop participants explored these challenges for 6 settings identified through a preworkshop questionnaire:

• National health organizations and governments
• Provincial/territorial health organizations and governments
• Regional health facilities and hospitals
• Medical clinics and offices (including primary care physicians and specialists)
• Educational institutions
• Research, industry and other settings.

The organization of this chapter reflects the work of the participants who divided up into small groups to consider their particular setting and

• To name unique factors (both supportive and restrictive) that influence the adoption of CPGs
• To identify successes and challenges in relation to the implementation of CPGs
• To choose the most important challenges and suggest strategies for addressing them
• To list additional challenges and strategies that are not of highest priority.

Because of the larger number of participants working in the first 2 settings, more challenges and strategies were developed for them.

This chapter is a summary of the results of these discussions and includes suggestions made by participants for addressing the challenges. Its purpose is not to list all the challenges and strategies that currently exist, but rather to represent the work of participants in each group and to serve as a starting point -- an idea bank -- for those wrestling with CPG implementation.

Recurring themes

• 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.
• 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.
• 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.
• Education (ED) -- Computer technology and the Internet were mentioned as important tools for education and for information systems and communication.
• Evaluation and outcome measurement (EV) -- Evaluation and outcome measurement are an essential component of the CPG process (Figure 1).
• Incentives for behaviour change (IC) -- Participants emphasized the need for appropriate incentives to motivate behaviour change in practitioners.
• 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.
• 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.

Supportive influences

• Key stakeholders are involved and committed.
• There is a national role in coordinating and facilitating the CPG effort.
• National-level action offers a broad perspective of experiences across provinces and territories, stakeholders, issues and international experiences.
• Opportunities exist to coordinate CPG development and implementation at the national level.

Restrictive influences

• There is no general agreement among practitioners that CPGs are effective; some resist CPGs as being too much like cookbook medicine.
• Some national CPG initiatives duplicate others.
• CPGs developed at the national level may not be appropriate at the local or community level due to social, economic and practice realities.
• There is a need to identify and guarantee funding for the development of guidelines.
• There is a concern that guidelines will become standards of practice.
• A general overload of information exists; CPGs are one item among many on decision-makers' desks.
• Conflicts exist between groups that develop CPGs and various sectors such as government, nongovernmental organizations and the pharmaceutical industry, who may have different agendas.

In addition to these, a number of other factors play a role.

• A broad, multidisciplinary approach is required, e.g., guidelines developed by specialists must apply to general and family practitioners and vice versa; the guideline implementation process should involve input from all relevant areas, e.g., practitioners, the public, payers, suppliers.
• There is a need for further discussion and understanding about how guidelines can take into account individual patient characteristics, such as age, sex and other comorbidities, and whether and how these CPGs can be incorporated into electronic patient records.
• Federal and provincial/territorial governments should be funding the CPG effort.
• Implementation should occur at the provincial/territorial and local levels.
• There is a need to differentiate between professional guidelines, such as office protocols and ethical issues, and CPGs.
• There are many international CPGs to choose among, only some of which may be appropriate in Canadian settings.

Successes and challenges

Successes include the fact that stakeholders are involved and that there is a role for national groups, particularly for database development. In addition, for successful guidelines such as those for diabetes and obstetric care, education has resulted in public empowerment.

National volunteer organizations and societies have also played a key role, e.g., promoting advanced cardiac life support certification or publishing CPGs and featuring them at meetings.

Because some local-level standards are accepted nationwide, e.g., Canadian Cancer Society standards on pain management, the essential role of community groups in CPG implementation has been confirmed.

Two further indicators of success are that guidelines have been implemented in some medical schools and in educational programs for other practitioners and the use of guidelines has led to further CPG development.

Priority challenges and strategies for national health organizations and governments Challenge Suggested strategies 1. To ensure adequate funding and support for the implementation of CPGs.* 1.1. Identify and coordinate existing resources. (RE) 1.2. Identify other possible funding sources. (RE) 1.3. Enter into partnerships with other groups such as industry and foundations; create guidelines for how to do this. (RE) 1.4. Lobby for funding. (RE) 2. To avoid duplication of effort by coordinating the development and implementation of CPGs 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. (CO) 2.2. Establish a clearinghouse (registry) for CPGs.† (CO) 2.3. Establish criteria for evaluating existing CPGs. (CO) 2.4. Use a multidisciplinary approach to prevent duplication of efforts. (CO, MC) 2.5. Make information appropriate to public needs. (CO) 3a. To develop practical methods for effecting change in practitioners' attitudes, skills and behaviours 3b. To develop practical methods for needs assessment and outcome evaluation related to changes in practitioners' behaviour 3.1. Use a variety of process and outcome measurements, e.g., knowledge changes, behavioural changes, patient satisfaction measures. (ED, EV, IC) 3.2. Identify utilization data. (EV) 3.3. Measure public expectations, e.g., through focus group studies. (EV) 3.4. Establish links with Canadian Institute for Health Information (CIHI) for clinical indicators. (CO, EV) 4. To develop methods of implementing CPGs effectively at the local level‡ 4.1. Develop an information system that allows primary caregivers to use information practically, on a patient-specific basis. (CR) 4.2. Ensure access to materials, e.g., to public and patient education tools that are developed nationally and used locally. (CR) 5. To empower members of the general public to stimulate the implementation of CPGs 5.1. Develop empowerment strategies that take into account the ethnic and cultural diversity of the public and health care practitioners. (PI) 5.2. Incorporate user-friendly language into public and patient information pieces related to CPG implementation. (PI) 5.3. Encourage use of the Internet. (PI, ED) 5.4. Develop user-friendly public education initiatives. (PI, ED) * Participants discussed, but did not come to agreement on, a suggestion to build CPG implementation into the health facilities accreditation process. A suggestion was also made that government should allocate a minimum of 1% of the health budget toward supporting guideline development and implementation. † 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 on page 1.) ‡ These methods and systems must be user friendly and contribute to office efficiency.

Additional challenges

Another challenge relates to copyright. Because guideline copyright is not an issue with the government in the United States, federal guidelines are distributed without charge. As a result they are widely available via various media and Canadians use them. How can we build support for the implementation of Canadian federal guidelines that have strict copyright restrictions for distribution and dissemination?

There was some discussion related to fears about overregulation. Several participants expressed a concern that tools could become rules or legal standards of practice, especially if they are endorsed by a national society.

Participants also talked about the need to focus on surviving the restructuring of Canada's health system while implementing CPGs. It was suggested that CPGs could assist the restructuring process by contributing to cost and resource efficiencies.

Provincial/territorial health organizations and governments

Supportive influences

• A provincial CPG program is the only forum available for multidisciplinary discussion of common approaches to community health issues.
• There is a perception that provincially developed guidelines have more validity than nationally developed guidelines.
• There is support from licensing bodies and professional associations and ready access to provincial/territorial data
• The development of guidelines can be tied to policy-making.
• Provincial/territorial organizations can influence funding for guidelines.
• Provincial/territorial medical associations are generally credible sources of information for practitioners.
• There is an opportunity for investment in information technology.
• Provincial/territorial agencies can use peer review as an implementation strategy.
• Pharmaceutical companies are potential resources for implementation processes, e.g., funding, evaluation studies.
• Provincial/territorial organizations usually have a solid base of expertise in CPGs, and there is potential for collaboration and networking.

Restrictive influences

• Guideline development is a lengthy process.
• Generally, there is limited funding for implementation.
• Some users of guidelines are suspicious about organizations linked with governments because they question the evidence base.
• Committee members may act as individuals rather than representing the organization as a whole.
• Provincial/territorial organizations are often seen as having a cost containment motive in promoting CPGs.
• Provincial/territorial organizations develop guidelines that may conflict with other professional bodies.

Successes and challenges

Successes include the number of credible organizations providing research and expertise, public participation, the fact that peer review by stakeholders ensures buy-in, evaluation and the focus on guidelines that are permissive or flexible rather than regulatory. In addition, administrative controls are present, and multiple interventions are common and often effective, e.g., approaches using print media, academic detailing and poster sessions.

There are champions who do good work in the dissemination and implementation of CPGs, including the establishment of incentives linked to reimbursement, e.g., Quebec.

The point was also made that there is greater success when guideline development occurs early in the introduction of a new technology.

Priority challenges and strategies for provincial/territorial health organizations and governments Challenge Suggested strategies 6. To reconcile the conflicting objectives of various stakeholders with respect to CPGs,* for example, public expectations vs cost effective health services new practices vs traditional reimbursement systems† savings and reinvestment vs budget reductions‡ perception that physicians want autonomy vs CPGs as directives progressing with development vs ability to measure results§ tools vs rules.¶ 6.1. Recognize that reconciling conflicting objectives is a problem. (MC) 6.2. Identify, analyse and understand conflicting objectives. (MC) 6.3. Come to an agreement among stakeholders about managing and resolving conflicts. (MC) 6.4. Communicate/implement previous strategies with stakeholders. (MC) 7. To produce a guideline that is likely to be adopted. 7.1. Select a topic that is relevant. (CR) 7.2. Ensure multidisciplinary involvement. (MC) 7.3. Obtain public participation. (PI) 7.4. Obtain acceptance of users. (IC) 7.5. Involve CME providers. (IC) 7.6. Obtain support of licensing or professional bodies. (IC) 7.7. Use more collaborative efforts to avoid duplication and to translate evidence and adapt to individual settings. (CO, MC) 7.8. Create a global multidisciplinary database such as CMA's CPG Infobase.(See chapter 1.) (CO, MC) 8. To incorporate CPGs into practice. 8.1. Ensure public support. (PI) 8.2. Establish the use of CPGs (where applicable) as a regular part of practice. (CR) 8.3. Promote the use of computer technology to facilitate access to information and promote utilization. (CR, ED) 8.4. Encourage CME and other educational activities. (ED) 8.5. Be explicit about the strength of evidence or lack of evidence.** (EV) 8.6. Identify situations where interventional treatment is not effective, e.g., where palliative care is more appropriate. (EV) 9. To keep CPGs current. 9.1. Support mechanisms for regular review and identification of obsolete evidence. State the frequency of updating in the CPG. (CR) 9.2. Create flexible implementation strategies that can be adjusted with new evidence, e.g., through a computer network. (CR) 10. To fund implementation strategies adequately. 10.1. Convince government and industry that this is an important activity requiring stable funding. (RE) 10.2. Recycle savings into further strategies. (RE) 10.3. Develop information systems to capture quality indicators and outcomes concurrently with interventions. (RE) 11. To educate practitioners in a timely manner regarding recent innovations.†† 11.1. Establish processes to identify new technologies and publish information about them immediately. (ED) 11.2. Establish provincial/territorial registries of new technology as a resource for practitioners. (ED) 11.3. Promote the discussion of CPGs through existing CME activities. (ED) 12. To educate the public with consistent messages on health interventions. 12.1. Increase funding for consumer associations to provide information and counter false information, e.g., Consumer reports on health care issues. (PI, ED) 12.2. Develop strategies for addressing sensationalized media coverage related to the implementation of CPGs, e.g., by educating the media. (PI, ED) 12.3. Provide tear-off sections on CPGs for public and patient use. (PI, ED) 12.4. Advertise new CPG releases. (PI, ED) 12.5. Communicate with the public in appropriate language. (PI, ED) 13. To achieve a balance between accountability in terms of cost and quality and professional autonomy. 13.1. Recognize stakeholders' interests explicitly and define areas of common interest. (MC) 13.2. Develop, validate and communicate an accountability frameworks to clarify stakeholder roles and responsibilities. (CO, CR) 13.3. Develop and implement a communication strategy that identifies the purpose, stakeholders, a process for evidence-based medicine and an iterative approach. (IC) 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. (PI, IC) 14. To define reliable outcome measurements that benchmark CPG effectiveness. Establish a working group to 14.1. Clarify stakeholder expectations at the beginning of the process and ensure that they are realistic, practical and linked to outcome measurement. (EV) 14.2. Define outcome measures at the beginning of the CPG development process. (EV) 14.3. Ensure, on an on-going basis, that comparison benchmarks are appropriate, relevant and accurate. (EV) 14.4. Clearly identify ownership of outcome information and how it will be used. (EV, MC) * Participants recognized that private payers may have a different perspective than public payers, medical organizations and others. † For example, where income loss and other reduced remuneration result from a change. ‡ For example, a CPG may create savings for the organization or the province that can be reinvested in other areas of health. § For example, administration may resist development of guidelines because of inability to measure results. ¶ There was considerable discussion about the need for guidelines that are tools that can be adapted to individual clinical situations rather than rules, as in a cookbook approach. ** Where evidence is lacking, those involved should indicate the need for research to provide that knowledge (see Guidelines for Canadian clinical practice guidelines1). †† Such as the use of excimer laser in photorefractive therapy.

Additional challenges

This group also identified the overall challenge of creating an inclusive, multidisciplinary process for guideline implementation and one that ensures that provincial guidelines are applicable for a wide range of practice contexts.

Another challenge is developing a local network to carry the provincial message to the level of the direct caregiver. Data are also needed to assist with needs assessments for identifying guidelines at the local level.

Group members mentioned the need to find the right incentives for behavioural change and, thus, to overcome disincentives in the system, e.g., method of financial payment for physicians. Participants recognized that some practitioners have a low level of interest in CPGs in general.

Regional health facilities and hospitals

Supportive influences

• Small hospitals and centres have less bureaucracy and, therefore, more flexibility in implementing CPGs.
• Teaching hospitals provide a learning environment where the clinician culture is evidence based.
• District board structures have resources for quality assurance programs including utilization and compliance with care maps and CPGs.
• Community-based institutions are closer to the interface between practitioners and patients. Those at the point of care have significant opportunities for making changes related to CPG implementation and for outcome measurement.

Restrictive influences

• Small hospitals often have limited resources.
• Evidence-based medicine is not yet part of the grassroots culture.
• The perceived threat to physician autonomy is unacceptable to some physicians.
• District board structures cannot monitor utilization and compliance with CPGs across multiple settings.
• Institutions may have cultures, communication systems and bureaucracies that can hamper CPG implementation.
• Agreement is difficult during CPG development if high-quality evidence is lacking.

Successes and challenges

Regional health facilities and hospitals have been successful in implementing CPGs, e.g., for meningitis, suicide risk, pediatric asthma, thrombolytic therapy and investigation of thrombosis, and care maps, e.g., for stroke, newborns, Cesarean sections, normal deliveries, gastroplasty, major joint replacements and asthma.

Priority challenges and strategies for regional health facilities and hospitals Challenge Suggested strategies 15. To find a balance between the use of evidence-based recommendations and clinical reality to ensure credibility of the guidelines.* 15.1. Involve local leaders in championing the CPG movement. (CR) 15.2. Involve skeptics in customizing CPGs for practice settings. (CR) 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. (CR, MC) 15.4. State clearly when evidence is inadequate; do not try to make CPGs more than what they are. (CR, EV) 15.5. Establish an ongoing process (after the initial implementation) to look at best evidence and outcomes. (CR, EV) 15.6. Ensure that the CPG can be applied in the clinical setting. (CR) 16. To ensure a receptive environment that will support the successful implementation of CPGs.† 16.1. Gain the commitment of senior organizational leaders, including the CEO. (CO) 16.2. Ensure availability of resources -- time, people and a priority ranking. (RE) 16.3. Develop a critical mass of supporters. (MC) 16.4. Establish trust. (MC) 16.5. Create and communicate incentives. (IC) 16.6. Identify the potential for early success and reinforce these successes. (CO) 17. To develop an organizational structure and process for implementing CPGs and care maps. 17.1. Incorporate all stages of the CPG development and dissemination process. (CO) 17.2. Ensure that committees and their mandates with respect to CPGs are clearly defined. (CO) 17.3. Develop a project plan or flow chart to integrate diverse elements, e.g., timelines and resources. (CO) 17.4. Coordinate groups working on guidelines within the facility. (CO) 17.5. Identify a leader to carry out the plan. (CO) 17.6. Define an accountability structure. (CO) 17.7. Establish linkages across the home­hospital­home continuum to ensure communication, understanding and acceptance. (CO) 17.8. Find the resources to pay for implementation. (CO, RE) 18. To align incentives for stakeholders. 18.1. Establish the return on investment for CPGs, e.g., improved quality, cost analysis. (IC, RE) 18.2. Recycle savings earned through CPGs, e.g., allocate a percentage of savings back to the program. (PI, IC, RE) 18.3. State clearly principles, goals and follow-through mechanisms. (IC, RE) 18.4. Establish a risk (investment) capital fund to support CPG development and implementation. (RE) 18.5. Look at all types of incentives, e.g., improved patient care. (IC, RE) 18.6. Find and commit resources to pay for implementation. (RE) 19. To build community connections, e.g., among health care practitioners and the public, with a focus on empowering the public. 19.1. Develop and implement an outreach program. (PI, ED) 19.2. Hold meetings to explain CPGs and enable buy-in by medical groups. (PI, ED) 19.3. Use video conferencing. (PI, ED) 19.4. Create computer linkages, e.g., CME, Internet at 2 levels -- health care practitioners and the public. (PI, CO, ED) 19.5. Create user-friendly public and patient information tools, such as pamphlets, and media coverage. (PI, ED) 19.6. Encourage community identification with practitioners and institutions. (PI) 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. (PI) 20. To measure outcomes that are valid and appropriate for all stakeholders. 20.1. Devise measurements that are comprehensive and reflect the entire population cost, i.e., based on patient management across the continuum of care. (EV) 20.2. Identify outcome measures by consensus among the stakeholders. (EV, MC) 20.3. Focus incentives on improving outcomes. (EV) 20.4. Identify valid, reliable tools for measuring outcomes. (EV) 20.5. Use clear, understandable language. (EV) * If the guidelines are to be credible, implementation must be examined in light of the quality of evidence and other considerations, such as the need for expensive equipment. † Overcoming this challenge demands an awareness of political considerations, such as the regionalization of health services in many parts of the country or who is going to provide leadership for health services implementation. This may require a cultural shift in both organizations and communities.

Additional challenges

Other challenges mentioned by this group include the need to customize CPGs to enable buy-in during the implementation phase and to facilitate cultural shifts in organizations so that they support CPG implementation.

Medical clinics and offices

Restrictive influences include the need for clearer definition of CPGs, i.e., the need to add care maps, algorithms, practice parameters, policies, standards, etc. In addition, busy family practices leave practitioners little time to read and adopt CPGs and they may be wary of the motives of CPG developers. Patient pressure should also be considered as a significant influence.

Successes and challenges

Participants identified a number of CPG products that are working well in the medical clinic and office setting, e.g., HIV guidelines; the anti-infective guidelines for community acquired infections; and laboratory practice guidelines such as those for prostate-specific antigen. Others commented that this is the third conference on CPGs and that we are making progress. In addition, the format and layout of CPGs has improved.

Priority challenges and strategies for medical clinics and offices Challenge Suggested strategies 21. To improve medical information systems for better access and utilization of CPGs. 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. (CR, ED, RE) 22. To establish the need for specific CPGs. 22.1. Establish a multidisciplinary focus group to assess needs. (EV, MC) 22.2. Obtain feedback at CME courses, conferences, etc. (EV) 23. To make CPG implementation more attractive to users. 23.1. Educate the public. (PI, ED) 23.2. Produce clear and concise CPGs that are easily understood. (PI) 23.3. Develop and stick with consistent messages. (PI) 23.4. Develop CME programs with CPGs as core information. (ED) 23.5. Educate health care practitioners about CPGs before the implementation phase. (ED)

Additional challenges

Preventing the proliferation of CPGs was also cited as a challenge. Participants suggested developing ways to use needs assessments, for example by asking users in what areas CPGs are required. There is also a need to work more closely with regional health authorities to ensure a collaborative approach to implementation.

Educational institutions

• Information is not being filtered to the public.
• There is a lack of consistency in the documents produced, e.g., information is not easily accessible or readable.
• CPGs are part of a total quality management (TQM) framework and should be recognized as such, developed and implemented in concert with an overall TQM program.
• There is a need for a coordinated source of accessible information provincially and nationally.
• Undergraduate and postgraduate training is changing; CPGs are not commonly used in training programs.
• Continuing education offices are not always targeted in guideline dissemination plans.
• There is a lack of models for effective dissemination.

Successes and challenges

Current successes include the fact that full-length CPGs are converted to short, 1- or 2-page algorithms, flow charts and structured abstracts; tool kits to help with the dissemination of some guidelines are also available, e.g., low-back pain, as are matched documents for practitioners and patients.

Small groups with an opinion leader are used to disseminate CPGs. CPGs are discussed during grand rounds, and there is an audit­peer review process as well.

Priority challenges and strategies for educational institutions Challenge Suggested strategies 24. To design a consistent presentation format for users. Participants focused on learning strategies and the use of a variety of formats, depending on the needs of users. 24.1. Address content issues 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. (ED) 24.2. Address format issues: create multiple media formats, i.e., electronic video, print, news; create multilingual formats; create multicultural formats. (ED) 25. To educate all users, i.e., create ways to make users aware of CPGs on a regular basis. 25.1. Place CPGs in the hands of the public to facilitate interaction with health care practitioners. (PI, ED) 25.2. Provide consumer groups, e.g., advocacy and self-help groups, with CPGs and educate them regarding their benefits. (PI, ED) 25.3. Provide information to the media in a standard format. (PI, ED) 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. (ED) 26. To make it practical for CPG users to monitor outcomes. 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. (EV) * The term "users" refers to both the public and health care practitioners.

Research, industry and other settings

Supportive influences

• Many CPGs are evidence based, high quality and user friendly.
• Regulatory bodies can help assess, develop and implement CPGs.
• Local input is valuable in promoting CPGs.
• Consumer associations are helpful in building acceptance.
• Collaboration with industry can increase dissemination and implementation.
• The current financial crisis is a driving force for the creation and adoption of CPGs.

Restrictive influences

• There is a lack of a CPG clearinghouse that critically evaluates the quality of CPGs.
• Suspicion exists that the key motivation for CPG implementation is cost containment.
• There is a concern that guidelines will become standards.
• There are no established ways to reinforce behavioural changes in health care practitioners.

Successes and challenges

The current financial crisis is a driving force in creating guidelines. In addition, multidisciplinary working groups are developing guidelines, which means that a variety of stakeholder groups and their needs are incorporated early in the process, encouraging widespread implementation. Some focused programs also exist, such as diabetes, which show where collaboration can be of value. Community practitioners are consulted as part of guideline development and, as a result, guidelines are based on needs defined by them beforehand. Guidelines are also being pretested in the community, with peer review, audit and feedback occurring in local areas.

The marketing of CPGs has improved. A variety of approaches such as print, videos and focus groups are being used to appeal to different groups. The media are assisting with implementation; they pay attention to CPG issues. Significant benefits also accrue from having credible opinion leaders who focus on the evidence.

Priority challenges and strategies for research, industry and other settings Challenge Suggested strategies 27. To coordinate CPG dissemination and implementation at the national level. 27.1. Re-align incentives for health care practitioners to encourage implementation of CPGs.* (CO) 27.2. Create better ways to market CPGs, e.g., reminder systems, working with local leaders and groups, ensuring that tools are user friendly. (PI, CO) 27.3. Create a national clearinghouse for CPGs, i.e., for evaluation, inventory and assistance with dissemination. (CO) 27.4. Use existing practitioner networks, e.g., organized multidisciplinary networks of small groups, Internet discussion groups. (CO) 28. To evaluate CPG outcomes 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. (EV) 28.2. Develop indicators to monitor changes introduced by CPGs. (EV). 28.3. Don't wait for the results of evaluation processes; continue with pilot studies and small projects; evolve gradually. (EV) 28.4. Reinforce the need for evaluation; encourage government and other agencies to provide financial resources in this area. (EV) 29. To recognize the role of various disciplines in the dissemination and implementation of CPGs. 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. (MC) 29.2. Change the notion in some physicians' minds that only they can do this work. (MC) 29.3. Find and make use of resources available worldwide, e.g., knowledge and skills. (CO, MC, RE) * This discussion was broad based. A concern was expressed that this strategy might be interpreted as being financial only, which is not the case.

Additional challenges

Additional challenges include addressing conflicts among members of working groups. There is also a need to address the issue of conflicting guidelines and how to keep guidelines up to date, particularly in rapidly changing situations, such as in the treatment of Helicobacter pylori infection and pelvic inflammatory disease.

When collaboration with industry occurs, there is a need to establish in advance the terms of reference and expectations of the process. (See also the national health organization and government setting. Workshop participants also discussed the need for practice guidelines for industry collaboration.)