4. Next steps

In closing, the workshop participants were asked two questions:

• What are you going to take back from this workshop to your organization in relation to CPG implementation?
• What can we, as members of this group, do together in relation to CPG implementation?

• Define the beginning and end processes better.
• Ensure multiple interventions at the local level to support implementation.
• Recognize the difference between evidence and expert opinion and know when each is appropriate.
• Ensure that physician leaders are involved in CPG development and implementation.
• Create clear links between objectives identified during CPG development and evaluation.
• Recognize and address the difficulties related to CPG implementation:
  • usually expensive
  • labour intensive
  • need to build an infrastructure within an organization to help it happen
  • the will to do it has to be present
  • those who develop CPGs are not usually those who implement them
  • you don't know whether the developed CPGs are implemented.

Focus on what happens up front

• Involve the public and other key players at an early stage; ensure that they know the agenda and expectations.
• Carry out a more comprehensive needs assessment.
• Ensure that CPG development strategies facilitate later implementation.
• Include a validation trial to ensure that guidelines are useful and to increase acceptance during implementation.
• Spend time in the community identifying challenges before proceeding.
• Build on existing structures in an organization rather than re-inventing them.
• Early in the process, refer new technology to health providers for opinions on its place in the health care system.
• Focus clearly on evidence-based approaches, particularly in areas of controversy or where high costs may be a factor..
• Build a healthy local implementation group, including key players as champions.

Collaborate more

• Place more emphasis on the involvement of all appropriate groups in guideline development.
• Look to other players in the community for support; network with other organizations.
• Recognize and build in substantive roles for the public.
• Create ways to share ideas in a multidisciplinary fashion.
• Work closely with the public to ensure that behaviour changes are system-wide.
• Ensure collaboration with industry and provider groups.
• Look for opportunities to collaborate on projects as an interim step in a nationally coordinated effort.
• Think about how to create a national coordinating role, e.g., create a standing CPG committee.

Build in mutual support mechanisms

• Use this handbook as a reference guide for addressing issues and learning from others.
• Ensure that our organization works more closely with the CMA, e.g., use the CMA database to build on local expertise.
• Ensure that CME is committed to the CPG process.
• Run a workshop on how to develop guidelines.
• Involve provincial medical associations so that they are a catalyst, e.g., in relation to quality of care and education.
• Recognize that CPGs are an evolving technology and that there is no best way to do them; they must be customized to suit the needs of particular situations, e.g., ensure that groups like this one can regroup and share experiences on a regular basis through electronic discussions, mailing lists, e-mail, news groups and occasionally face to face.
• Know about and recognize the spectrum of contributions and involvement from national to local levels.
• Increase awareness regarding duplication and ways to avoid it.
• Focus the next workshop on evaluation issues.
• Be sensitive about the inclusion of French-speaking colleagues and groups.
• Contribute to shifting attitudes in relation to CPGs to ensure that they are adopted.

Focus on funding

• Expend more effort convincing government that this is a good investment of health dollars.
• Get the pharmaceutical technology companies involved as funders.
• Ensure that those involved in policy are aware of the importance of finding funds.
• Push for allocation of more resources to this area.

Expand communication initiatives

• Do more information sharing in local environments.
• Inform and educate the public.
• Expand the use of electronic information and decision-making systems.
• Advise national specialty associations of the results of this workshop.
• Create an Internet discussion group on implementing CPGs.
• Create a user-pay web site for guidelines.
• Create ways to share experiences with others involved in implementing CPGs.

Build in evaluation

• Build in evaluation and updating from the start.
• Celebrate what we do well; don't always focus on the problems.
• Ensure a clear focus on indicators and health outcomes.

Questions asked by participants

• Do we need to re-examine the value of CPGs if we can't find a way to coordinate CPG development, implementation and evaluation at the national level?
• Should we copyright the guidelines?

As individuals

• Review the draft of this handbook and provide feedback.
• Demystify CPGs for colleagues and others by supporting their benefits and act as a role model by using CPGs in practice.
• Encourage a positive perspective on CPGs in our own organizations and day-to-day lives.
• Write an editorial for the association newsletter describing the pros and cons of guideline development and hold a vote at the annual general meeting to determine whether they are needed.
• Continue to encourage and support evidence-based practice.
• Stay plugged into the CPG network in relation to development and implementation issues.
• Share the successes of CPGs with others.

As national and provincial organizations

• Create a national umbrella strategy for CPGs in relation to evidence-based medicine and the critical appraisal of practice.
• Clarify the relation between CPGs and care maps.
• Set priorities for future CPG activities.
• Ask the federal government to facilitate national data collection in relation to evaluation of CPGs.
• Encourage the CMA to
• develop next steps in terms of evaluation
• develop case examples that are comparative and describe what works and what doesn't
• develop an Internet discussion group
• continue to maintain and promote the CPG inventory.
• Focus on information sharing, e.g., practical tips such as those provided by panel members at this workshop.

Through enhanced communication

• Take this handbook back to our respective organizations and encourage them to distribute it and use it.
• Demystify CPGs and perceived threats to health care practitioners.
• Encourage 2-way communication between our organizations and national and provincial groups.
• Make a commitment to improve communication as a strategy for avoiding duplication.
• Promote and support the national CPG registry.

Through training, development and education

• Promote and organize skill development workshops on various aspects of CPG implementation, e.g., at the Ottawa conference on the assessment of clinical competence.
• Create mechanisms for reinforcement, common infrastructure technology and tools for development, diffusion and maintenance.
• Create a common approach to education of the public and of consumer bodies.

In support of funding

• Advocate funding on a cost­benefit basis.
• Create a trust fund for CPG development, implementation and evaluation with moneys from pharmaceutical companies.
• Involve technology companies in providing funding.

Through networking

• Organize provincial meetings to develop workplans and share information.
• Continue to meet with interested associates in other disciplines.
• Use this group as a network for support and guidance in relation to the CPG process.

Through evaluation

• Review and revise CPGs regularly.
• Have an alternative association do guidelines review, e.g., CIHI.

And finally, a closing comment from 1 group summed up the positive energy at the workshop: