Overall CPG Development Process
The multidisciplinary guideline subcommittee should brainstorm early to identify target users, stakeholders, and settings. In addition, it may be that in the literature collection phase, some of the articles identified for review by the team would help identify additional barriers relevant to the specific guideline.
It is the specific role of the Implementation Scientist to bring an implementation focus to the guideline development process and to create an implementation toolkit to accelerate guidelines being practically used to improve the care of children. An example is the toolkit for the Genetics in Primary Care Institute-Quality Improvement Project.
Specific deliverables for the Implementation Scientist include:
Specific tools for front-line clinicians to use to implement these changes, such as mock order sets, flow diagrams of ideal processes, educational materials, shared decision tools, billing codes to electronically identify data, examples of past successful projects, and/or contacts at institutions who have successfully implemented these types of projects and are willing to be contacted by others; and
A dissemination plan for how this toolkit will be shared with the maximum number of clinicians.
Additional deliverables may include:
Overall aim outcome measure statement for guideline
Specific measures, including numerators and denominators, to measure 1) outcomes, 2) processes, and 3) balancing measures related to understanding if these guidelines have been effectively implemented; and
Key driver diagram related to the guideline and its implementation.
Pediatric providers will face many barriers to implementing recommendations and guidelines in their practice setting. An important overarching goal is to change physician behavior but doing so in a dynamic health care environment can be challenging. Cabana and colleagues provide an excellent framework for the stages leading to behavior change: knowledge, attitudes, and eventually, behavior.19 Each stage contains a specific set of barriers preventing guideline adoption:
Lack of familiarity
Lack of awareness
Lack of agreement with specific guidelines
Lack of agreement with guidelines in general
Lack of outcome expectancy
Lack of self-efficacy
Lack of motivation/inertia of previous practice
External Barriers: Patient factors
External Barriers: Guideline factors
External Barriers: Environmental factors