What do we want to know?
Clinical, public health and social care guidance provide evidence-based recommendations on how professionals and commissioners working within these fields should care for patients, service users and the wider public. Evidence-based clinical guidance aims to reduce variation in practice and improve levels of patient and service user care, while at the same time allowing clinical freedom for individual practitioners. The guidance produced by the National Institute for Health and Care Excellence (NICE) are not mandatory, although NICE does set out a business case in terms of the clinical and cost-effectiveness for implementation. Implementation in this sense signifies the active planned processes that take place to enable guidance-based best practice to become routinely embedded within day-to-day activity.
There is growing recognition that getting evidence to influence and change practice is a complex undertaking. Despite a growth in the evidence base in this area, there remain gaps in understanding which types of implementation strategies are most effective for which types of guidance, for which audiences and in which circumstances. This review sought to investigate the strategies used to implement NICE guidance in routine practice, and particularly to examine the impact of implementation strategies operationalised by national level organisations and networks.
Who wants to know?
This report was commissioned by the NICE, although the findings are likely to be of wider interest to a range of stakeholders interested in guideline implementation across clinical, social care and public health decision-making.
What did we find?
We screened over 4,300 records and identified 87 research studies (both observational and intervention studies) that were focussed on the implementation of NICE guidance in practice and meeting our inclusion criteria. Studies examining national strategies or processes were in the minority, accounting for 21% of the 87 studies identified. In contrast studies that examined local practices and implementation interventions were much more common, with 37% of studies examining implementation within single institutions. Venous thromboembolism and mental health guidance are the most frequent foci of studies aiming to understand and improve implementation processes.
Locally, frequently deployed methods of implementation included audit and feedback, educational materials, educational meetings and processes aimed at developing consensus. Nationally, a substantial degree of activity was being conducted, although many of these actions such as awareness raising, publicising, disseminating and endorsement activities that support guidance implementation were not evaluated. This represents a gulf in our understanding of how national level organisations can be effective supporters of guideline implementation. Nevertheless a number of potential green-shoots were identified including around the development of national and online communities of practice and the potential (although largely unexplored) role of interventions aimed at changing organisational culture such as accreditation schemes. These could support more localised and tailored activities and provide a catalyst to improved organisational management processes facilitating the implementation of guidance. National level activities could also stimulate conversations to occur between clinical staff and managers that may not ordinarily occur.
There is no failsafe mechanism or activity around implementation of guidance, and while there exists a large body of literature in this arena, there remain a number of gaps in the literature, which are translated into research recommendations in the report.
How did we get these results and what are the key limitations?
We conducted a scoping review of the literature (employing many of the methods undertaken in conducting a full systematic review). However, we focussed in greater detail on part of the literature examining national stakeholders and activities. To ensure that broader learning around guidance implementation was not missed, further searching of systematic reviews (particularly those published by the Cochrane Effective Practice and Organisation of Care (EPOC) review groups) also took place. We also undertook detailed and systematic web searching among almost 60 national organisations.
There are limitations to the results presented in this report, which represented a rapid review of the literature. One of the main limitations is that this report deliberately focussed away from the multitude of implementation activities that are being conducted by NICE itself, and in this sense this report is an incomplete depiction of the implementation landscape. The second main limitation is publication bias, which is likely to mean that we are unable to identify those implementation interventions that are less likely to change practice. There are also limitations to the review methods and approach taken in web searching (as opposed to more in-depth activities that could have taken place).
For more information please email Dylan Kneale: D.Kneale@ucl.ac.uk
This report should be cited as:
Kneale D, Goldman R, Thomas J (2016) A scoping review characterising the activities and landscape around implementing NICE guidance. London: EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London. ISBN: 978-1-907345-94-4
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