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      Exploring the solutions to the inherent perils of (the multitude of) guidelines – a focus group study of stakeholders’ perceptions

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          Abstract

          Background

          Hospital boards have the responsibility to ensure compliance of hospital staff with guidelines and other norms, but they have struggled to do so. The current study aims to identify possible solutions that address the whole chain of guideline and norm production, use and enforcement and that could help hospital boards and management cope with norms and guidelines.

          Methods

          We performed a qualitative study of three focus groups involving a total of 28 participants. In the third focus group, no new themes emerged, indicating that saturation was achieved. Focus group discussions were audiotaped and transcribed verbatim. Results were coded, and three themes emerged from the results. Thick description with selected key quotes is used to display the items in the result section.

          Results

          In the first instance, norm developers, norm enforcers, and norm users acknowledged and reformulated the problem before they suggested solutions. The proposed concrete solutions, such as a clear description of the division of tasks within guidelines, clarity about the purpose of guideline recommendations, a maximum number of quality indicators for hospitals and implementation of an ensuring proper Information Technology (IT) infrastructure.

          Conclusions

          This study aimed to find solutions for the problems that hospitals encounter in managing a multitude of norms and guidelines. Participants in this study acknowledged the fact that norms and guidelines have become difficult to manage at the hospital level and four potential solutions were identified.

          Trial registration

          The study was retrospectively registered on the 21st of July in 2016 in the Dutch Trial Register as NL4061.

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          Most cited references19

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          Barriers and Strategies in Guideline Implementation—A Scoping Review

          Research indicates that clinical guidelines are often not applied. The success of their implementation depends on the consideration of a variety of barriers and the use of adequate strategies to overcome them. Therefore, this scoping review aims to describe and categorize the most important barriers to guideline implementation. Furthermore, it provides an overview of different kinds of suitable strategies that are tailored to overcome these barriers. The search algorithm led to the identification of 1659 articles in PubMed. Overall, 69 articles were included in the data synthesis. The content of these articles was analysed by using a qualitative synthesis approach, to extract the most important information on barriers and strategies. The barriers to guideline implementation can be differentiated into personal factors, guideline-related factors, and external factors. The scoping review revealed the following aspects as central elements of successful strategies for guideline implementation: dissemination, education and training, social interaction, decision support systems and standing orders. Available evidence indicates that a structured implementation can improve adherence to guidelines. Therefore, the barriers to guideline implementation and adherence need to be analysed in advance so that strategies that are tailored to the specific setting and target groups can be developed.
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            How can we improve guideline use? A conceptual framework of implementability

            Background Guidelines continue to be underutilized, and a variety of strategies to improve their use have been suboptimal. Modifying guideline features represents an alternative, but untested way to promote their use. The purpose of this study was to identify and define features that facilitate guideline use, and examine whether and how they are included in current guidelines. Methods A guideline implementability framework was developed by reviewing the implementation science literature. We then examined whether guidelines included these, or additional implementability elements. Data were extracted from publicly available high quality guidelines reflecting primary and institutional care, reviewed independently by two individuals, who through discussion resolved conflicts, then by the research team. Results The final implementability framework included 22 elements organized in the domains of adaptability, usability, validity, applicability, communicability, accommodation, implementation, and evaluation. Data were extracted from 20 guidelines on the management of diabetes, hypertension, leg ulcer, and heart failure. Most contained a large volume of graded, narrative evidence, and tables featuring complementary clinical information. Few contained additional features that could improve guideline use. These included alternate versions for different users and purposes, summaries of evidence and recommendations, information to facilitate interaction with and involvement of patients, details of resource implications, and instructions on how to locally promote and monitor guideline use. There were no consistent trends by guideline topic. Conclusions Numerous opportunities were identified by which guidelines could be modified to support various types of decision making by different users. New governance structures may be required to accommodate development of guidelines with these features. Further research is needed to validate the proposed framework of guideline implementability, develop methods for preparing this information, and evaluate how inclusion of this information influences guideline use.
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              Resisting Evidence: The Study of Evidence-Based Medicine as a Contemporary Social Movement

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                Author and article information

                Contributors
                louise.blume@medtronic.com
                jamiu.busari@maastrichtuniversity.nl
                Nico.vanWeert@QKwaliteitsadvies.nl
                DDelnoij@zinl.nl
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                1472-6963
                19 June 2019
                19 June 2019
                2019
                : 19
                : 395
                Affiliations
                [1 ]ISNI 0000 0004 0376 9704, GRID grid.473020.2, Medtronic GmbH, ; Meerbusch, Germany
                [2 ]Department of Pediatrics, Zuyderland Medical Centrum, Heerlen, Netherlands
                [3 ]ISNI 0000 0001 0943 3265, GRID grid.12295.3d, Tilburg School of Social and Behavioural Sciences, Tranzo, Scientific Center for Transformation in Care and Welfare, , Tilburg, University, ; Tilburg, Netherlands
                [4 ]ISNI 0000 0001 0481 6099, GRID grid.5012.6, Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, , University of Maastricht, ; Maastricht, Netherlands
                [5 ]Q! B.V, Nijmegen, Netherlands
                [6 ]ISNI 0000 0004 0623 3817, GRID grid.454101.5, National Health Care Institute, , Zorginstituut Nederland, ; Diemen, Netherlands
                [7 ]ISNI 0000000092621349, GRID grid.6906.9, Erasmus School of Health Policy & Management (ESPHM), , Erasmus University Rotterdam, ; Rotterdam, Netherlands
                Author information
                http://orcid.org/0000-0002-6347-679X
                Article
                4261
                10.1186/s12913-019-4261-4
                6584987
                31217013
                94d1f87a-05cd-4685-8994-45d0e9fb5cea
                © The Author(s). 2019

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 12 April 2018
                : 13 June 2019
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2019

                Health & Social care
                guidelines,hospitals,implementation,external demands,compliance,standardisation,requirements,regulations,stakeholders

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