In our previous article, we’ve identified the specific guideline(s) we’re focused on implementing, measured existing practices at the organization, and also identified any potential barriers to implementation, it’s time to focus on determination and prioritization of specific interventions.
Interventions may be targeted at one or more stakeholders, including:
- Physicians
- Nurses
- Pharmacists
- Health IT
- Health Business and Administration
- Patients
- And More
Strategies for implementation and specific interventions include both top-down and bottom-up approaches.
A top-down approach is linear, and all intervention strategies are formed and operated via a central source. Examples of interventions in a top-down approach include:
- Distribution of reference and educational tools
- Ongoing training
- Requiring or mandating a specific change
In a bottom-up approach, the efforts are decentralized, and the interventions are initial at a community or local level. Examples include:
- Capture and share local knowledge
- Organize clinician implementation team meetings
There is little evidence to suggest one approach works better than the other, so it is suggested to account for both approaches, and also implement a level of trial and error to better determine what approaches work best at your specific organization.
There are many different interventions to consider. Below is a table that broadly identifies a few of the most common types of interventions:
| Intervention | Description |
|---|---|
| Academic detailing | Personal visits by a trained person to health workers in their own settings, to provide information with the aim of changing practice |
| Audit & feedback mechanisms | A summary of health workers’ performance over a specified period of time, given to them in a written, electronic or verbal format. The summary may include recommendations for clinical action |
| Case management | Introduction, modification or removal of strategies to improve the coordination and continuity of delivery of services, i.e. improving the management of one “case” (patient) |
| Communities of practice | Groups of people with a common interest who deepen their knowledge and expertise in this area by interacting on an ongoing basis |
| Community mobilization | Processes that enable people to organize among themselves |
| Continuous quality improvement | An iterative process to review and improve care that includes involvement of healthcare teams, analysis of a process or system, a structured process improvement method or problem-solving approach, and use of data analysis to assess changes [67] |
| Creation of multidisciplinary implementation teams | Creation of a new team of health professionals of different disciplines or additions of new members to the team who work together to care for patients |
| Development of care pathways | Aim to link evidence to practice for specific health conditions and local arrangements for delivering care |
| Educational games | The use of games as an educational strategy to improve standards of care |
| Educational materials | Distribution of published or printed recommendations for clinical care, including clinical practice guidelines |
| Educational meetings | Courses, workshops, conferences or other educational meetings |
| Financial interventions | Targeted financial incentives for health professionals and healthcare organizations |
| Foster more communication between providers | Systems or strategies for improving the communication between healthcare providers, for example systems to improve immunization coverage |
| Involve local opinion leaders & champions | The identification and use of identifiable local opinion leaders to promote good clinical practice |
| Involvement of Information & communication technology | ICT used by healthcare organizations to manage the delivery of healthcare, and to deliver healthcare |
| Local consensus processes | Formal or informal local consensus processes, for example agreeing on a clinical protocol to manage a patient group, adapting a guideline for a local health system or promoting the implementation of guidelines |
| Monitoring the performance of the delivery of healthcare | Monitoring of health services by individuals or healthcare organizations, for example by comparing with an external standard |
| Patient-mediated Intervention | Any intervention aimed at changing the performance of healthcare professionals through interactions with patients, or information provided by or to patients |
| Reminders | Manual or computerized interventions that prompt health workers to perform an action during a consultation with a patient, for example computer decision support systems |
| Structural intervention | Changes to the setting/site of service delivery, physical structure, facilities and equipment, and medical records systems, among others |
While the number of potential interventions is numerous, you should prioritize the possible interventions based on the barriers identified in Step 3. Prioritization should also take into account any direct costs and/or opportunity costs associated with the interventions, as well as the potential benefits.
So to recap, when prioritizing specific interventions
- What are the direct and indirect or opportunity costs associated with these interventions?
- What are the potential direct or indirect benefits associated with these interventions?
- Who needs to be involved, and who needs to approve of these strategies and interventions?
At the end of the day, the goal is to overcome the potential barriers and enhance enablers outlined in Step 3. A valuable format for tracking this is outlined in the table below:
| Guideline | Guideline Recommendation(s) | Implementation Barriers | Implementation Enablers | Interventions Identified | Lead(s) for Delivery of Intervention(s) | Expected Outcome & Verification |
|---|---|---|---|---|---|---|
There are a number of contextual factors that appear to facilitate greater success of intervention strategies. These include:
- Materials distributed to stakeholders in short and simple format that are easy to understand and use
- Interventions that need minimal resources needed to implement
- Involving end-users in intervention development, implementation, and testing
- Use of computerized guidelines in practice settings
- Formal leadership, especially when leaders' and champions' social influence is recognized
- Local management support and enthusiasm
- Adequate time to promote new practice
- Provider incentives
- Multifaceted interventions are more likely to be effective than single interventions
- Multidisciplinary teams, coordination of care, pace of change, a blame-free culture, and a history of quality improvement
- Low-baseline adherence
- Integration with computers used in practice
- Reminders automatic—clinicians not required to seek information
In the next post of our clinical guidelines implementation strategies series, we will take a closer look at step 5 - implementation of the plan and specific interventions.
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