Implementing clinical quidelines in psychiatry : a qualitative study of perceived facilitators and barriers

BACKGROUND: Translating scientific evidence into daily practice is complex. Clinical guidelines can improve health care delivery, but there are a number of challenges in guideline adoption and implementation. Factors influencing the effective implementation of guidelines remain poorly understood. Understanding of barriers and facilitators is important for development of effective implementation strategies. The aim of this study was to determine perceived facilitators and barriers to guideline implementation and clinical compliance to guidelines for depression in psychiatric care. METHODS: This qualitative study was conducted at two psychiatric clinics in Stockholm, Sweden. The implementation activities at one of the clinics included local implementation teams, seminars, regular feedback and academic detailing. The other clinic served as a control and only received guidelines by post. Data were collected from three focus groups and 28 individual, semi-structured interviews. Content analysis was used to identify themes emerging from the interview data. RESULTS: The identified barriers to, and facilitators of, the implementation of guidelines could be classified into three major categories: (1) organizational resources, (2) health care professionals' individual characteristics and (3) perception of guidelines and implementation strategies. The practitioners in the implementation team and at control clinics differed in three main areas: (1) concerns about control over professional practice, (2) beliefs about evidence-based practice and (3) suspicions about financial motives for guideline introduction.Peer reviewe

Supported local implementation of clinical guidelines in psychiatry: a two-year follow-up

BACKGROUND: The gap between evidence-based guidelines for clinical care and their use in medical settings is well recognized and widespread. Only a few implementation studies of psychiatric guidelines have been carried out, and there is a lack of studies on their long-term effects.The aim of this study was to measure compliance to clinical guidelines for treatment of patients with depression and patients with suicidal behaviours, two years after an actively supported implementation. METHODS: Six psychiatric clinics in Stockholm, Sweden, participated in an implementation of the guidelines. The guidelines were actively implemented at four of them, and the other two only received the guidelines and served as controls. The implementation activities included local implementation teams, seminars, regular feedback, and academic outreach visits. Compliance to guidelines was measured using quality indicators derived from the guidelines. At baseline, measurements of quality indicators, part of the guidelines, were abstracted from medical records in order to analyze the gap between clinical guidelines and current practice. On the basis of this, a series of seminars was conducted to introduce the guidelines according to local needs. Local multidisciplinary teams were established to monitor the process. Data collection took place after 6, 12, and 24 months and a total of 2,165 patient records were included in the study. RESULTS: The documentation of the quality indicators improved from baseline in the four clinics with an active implementation, whereas there were no changes, or a decline, in the two control clinics. The increase was recorded at six months, and persisted over 12 and 24 months. CONCLUSIONS: Compliance to the guidelines increased after active implementation and was sustained over the two-year follow-up. These results indicate that active local implementation of clinical guidelines involving clinicians can change behaviour and maintain compliance.Peer reviewe

An approach to measure compliance to clinical guidelines in psychiatric care

<p>Abstract</p> <p>Background</p> <p>The aim of this study was to measure six months compliance to Swedish clinical guidelines in psychiatric care after an active supported implementation process, using structured measures derived from the guidelines.</p> <p>Methods</p> <p>In this observational study four psychiatric clinics each participated in active implementation of the clinical guidelines for the assessment and treatment of depression and guidelines for assessment and treatment of patients with suicidal behaviours developed by The Stockholm Medical Advisory Board for Psychiatry. The implementation programme included seminars, local implementation teams, regular feedback and academic visits. Additionally two clinics only received the guidelines and served as controls. Compliance to guidelines was measured using indicators, which operationalised requirements of preferred clinical practice. 725 patient records were included, 365 before the implementation and 360 six months after.</p> <p>Results</p> <p>Analyses of indicators registered showed that the actively implementing clinics significantly improved their compliance to the guidelines. The total score differed significantly between implementation clinics and control clinics for management of depression (mean scores 9.5 (1.3) versus 5.0 (1.5), p < 0.001) as well as for the management of suicide (mean scores 8.1 (2.3) versus 4.5 (1.9), p < 0.001). No changes were found in the control clinics and only one of the OR was significant.</p> <p>Conclusion</p> <p>Compliance to clinical guidelines measured by process indicators of required clinical practice was enhanced by an active implementation.</p

Turning guidelines into clinical practice : Findings from an implementation study

Aim: The general aim of this thesis is to describe factors of importance when implementing clinical guidelines in psychiatry, and more specifically contribute to a better understanding of the implementation process. The specific aims are: Study I, to investigate a tailored implementation programme for implementing clinical guidelines for depression and suicidal patients, and to evaluate the compliance to guidelines after 6 months. In Study II, to further investigate compliance after 12 and 24 months. In Study III, to more specifically investigate perceptions of clinical guidelines and to identify barriers to, and facilitators of, implementation. Finally, in Study IV, to evaluate clinical outcomes and patient costs comparing patients who received psychiatric care according to guidelines with those who received treatment as usual. Methods: Six psychiatric clinics in Stockholm, Sweden participated in implementing clinical guidelines for depression and suicidal patients. The guidelines were actively implemented at four clinics, and the other two only received the guidelines and served as controls. In Study I, 725 patient were included, 365 before implementation and 360 six months after. Compliance to guidelines was measured using quality indicators derived from the guidelines. In Study II, further data collection took place after 12 and 24 months and a total of 2,165 patients were included. Study III was qualitative and conducted at two of the psychiatric clinics. Data were collected using three focus groups and 28 individual, semi-structured interviews. Content analysis was used to identify themes emerging from the interview data. Study IV included the two clinics that implemented the clinical guidelines for depression and the control clinic that only received the guidelines. A cost analysis of guideline implementation was performed and patient outcomes were assessed after 12 months. Results: In Study I, the implementing clinics significantly improved their recording of quality indicators compared to the control clinics. No changes were found in the control clinics. In Study II, the difference between the implementation clinics and control clinics persisted over 12 and 24 months. In Study III, the practitioners in the implementation team and at control clinics differed in three main areas: (1) concerns about control over professional practice, (2) beliefs about evidence-based practice and (3) suspicions about financial motives for guideline introduction. In Study IV, the psychiatric outcome measures improved significantly at the clinics with an active implementation compared to the control clinic. The costs were also lower. Conclusion: Our results showed that compliance to the guidelines was better at the clinics with an active implementation than at the control clinics and that this difference was sustained after 12 and 24 months. Additionally, patients at the intervention clinics were significantly more likely to be clinically improved, and at a lower cost

Implementing clinical guidelines in psychiatry: a qualitative study of perceived facilitators and barriers

Abstract Background Translating scientific evidence into daily practice is complex. Clinical guidelines can improve health care delivery, but there are a number of challenges in guideline adoption and implementation. Factors influencing the effective implementation of guidelines remain poorly understood. Understanding of barriers and facilitators is important for development of effective implementation strategies. The aim of this study was to determine perceived facilitators and barriers to guideline implementation and clinical compliance to guidelines for depression in psychiatric care. Methods This qualitative study was conducted at two psychiatric clinics in Stockholm, Sweden. The implementation activities at one of the clinics included local implementation teams, seminars, regular feedback and academic detailing. The other clinic served as a control and only received guidelines by post. Data were collected from three focus groups and 28 individual, semi-structured interviews. Content analysis was used to identify themes emerging from the interview data. Results The identified barriers to, and facilitators of, the implementation of guidelines could be classified into three major categories: (1) organizational resources, (2) health care professionals' individual characteristics and (3) perception of guidelines and implementation strategies. The practitioners in the implementation team and at control clinics differed in three main areas: (1) concerns about control over professional practice, (2) beliefs about evidence-based practice and (3) suspicions about financial motives for guideline introduction. Conclusions Identifying the barriers to, and facilitators of, the adoption of recommendations is an important way of achieving efficient implementation strategies. The findings of this study suggest that the adoption of guidelines may be improved if local health professionals actively participate in an ongoing implementation process and identify efficient strategies to overcome barriers on an organizational and individual level. Getting evidence into practice and implementing clinical guidelines are dependent upon more than practitioners' motivation. There are factors in the local context, e.g. culture and leadership, evaluation, feedback on performance and facilitation, -that are likely to be equally influential.</p