Clinical Practice Guideline Dissemination and Implementation Strategies for Healthcare Teams and Team-Based Practice: a systematic review.

Associate reviewers: Lindsay MacKenzie, MSc Paola Durando BA, MLS, Assoc. Librn. Margo Paterson, PhD, OT Reg (Ont) Carly Turner BA (Hons) Background Healthcare services and their delivery are receiving a great deal of attention in the current literature and the demand for an increase in collaborative care has emerged from many task force reports and governmental policies (both federal and provincial).1-7 The Canadian Association of Occupational Therapists defines collaborative care as “the positive interaction of two or more health professionals, who bring their unique skills and knowledge, to assist patients/clients and families with their health decisions.”8 This demand calls for inter-professional teams of health care providers to work collaboratively in the provision of integrated and continuous healthcare. Team-based healthcare and practice has been widely argued to provide not only improved efficiency and quality of service,3;5;9 but also cost reductions,4 and increased job satisfaction.3;6;9 In recent years healthcare has focused on using evidence-based practice more to inform clinical decisions because firstly, it improves patient care and outcomes, and secondly, it is associated with cost-effectiveness and increased job satisfaction.10-12 Sackett et al.13 define evidence-based medicine as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (p.71) Clinical decision-making informed by evidence-based practice has increased with the development and utilization of clinical practice guidelines. These guidelines are defined by Field and Lohr14 as “systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances.” (p.38) The use of clinical guidelines improves the effectiveness and efficiency of healthcare while reducing inappropriate variations in practice.15 Interestingly, West et al.16 report that in order to ensure effective collaboration, teams require explicit, appropriate tasks and goals and clear meaningful roles for each individual; criteria which could be accomplished through the implementation of clear and systematic guidelines to assist in practitioner decision-making. The current emphasis on both collaborative team practice and the implementation of clinical practice guidelines predicts great improvements in healthcare delivery and patient outcomes. However, further research in this area is needed to evaluate the various implementation and dissemination strategies and their effectiveness. A previous systematic review by Grimshaw et al.17 examined the effectiveness and efficiency of guideline dissemination and implementation strategies in the medical profession. Their findings highlighted the need for decision-makers to carefully consider the environment into which the guideline may be implemented, as well as the benefits and costs to be incurred through both the implementation strategy, and the change in provider behaviour. They noted that despite an increased interest in guidelines, uncertainty pertaining to the effectiveness behind some of the different strategies remained. Similarly, a systematic review by Thomas et al.18 focused on the implementation and dissemination of practice guidelines in nursing and professions allied to medicine (i.e., physiotherapists, occupational therapists, midwives, dentists, hygienists, pharmacists, and other health care professionals) indicated that there was evidence that guideline implementation was effective in improving both the processes and outcomes of healthcare specific to these professions. This review is currently in the process of being updated by the Cochrane Collaboration's Effective Practice and Organization of Care (EPOC) group. To date, no systematic review has been performed to evaluate the effectiveness of clinical guideline implementation for team-based, collaborative practice. The current trend towards collaborative practice clearly indicates that there is a need to evaluate guideline implementation and dissemination strategies and their appropriateness for the team-based healthcare setting. This evidence will contribute to the improvement of current healthcare delivery and outcomes. Review question/objective The objective of this systematic review is to identify the effectiveness of different clinical practice guideline implementation strategies on team-based practice and/or patient outcomes. Inclusion criteria Types of studies This review will consider any randomised controlled trials (RCTs). In the absence of RCTs other research designs, such as quasi-randomised controlled trials, cohort studies, statistical studies, before and after studies, prospective studies, experimental or non-experimental studies, longitudinal studies, time series and observational studies, will be considered for inclusion in a narrative summary to enable the identification of current best evidence. Studies investigating the economic effectiveness of dissemination and/or implementation of interventions will also be considered. Types of participants This review will investigate studies concerning health care teams who collaborate in an active or proactive way. Studies involving multiple professions who simply follow the same guideline will be excluded from the review. This review will consider studies that include team-based practices, i.e. practices including two or more professions or disciplines (for example medicine, nursing, occupational therapy, physical therapy, dietetics/nutrition, speech language therapy, social work, dentists/hygienists, laboratory services, pharmacy, health administration). Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the implementation and/or dissemination of clinical practice guidelines. For this review the definition of clinical practice guidelines is broad and does not require that term to be explicitly stated. For inclusion in this review, clinical practice guidelines are considered to be any systematically developed statements used to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. Types of outcome measures This review will consider studies that include the following outcome measures: any objective measure of change in provider behaviour and/or patient outcome resulting from the assimilation of the clinical practice guideline specific to the implementation/ dissemination strategy. Search strategy for identification of studies The search strategy aims to find both published and unpublished studies for 1994 - 2007. A three-step search strategy will be utilized in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Results will be limited to English language articles. The databases to be searched include: AMED CINAHL Cochrane Database of Systematic Reviews Centre of Reviews and Dissemination (CRD) EMBASE ERIC Healthstar MEDLINE PsycINFO Clinical Pharmacology Clinical Reference Systems Current Contents Biomed Central PubMed TRIP (Turning Research into Practice) Initial keywords to be used will be: guideline$; clinical practice; clinical guideline$; clinical implementation guideline; interdisciplinary; interprofessional; team$; teamwork or team work; collaborat$; dissemination; implement$; evaluat$; uptake; validation; effective$ Grey literature search will include the following: Centres for Health Evidence CCSA (Canadian Centre on Substance Abuse) Current Controlled Trials Dissertation Abstracts EPPI-Centre AHRQ (Agency for Healthcare Research and Quality) QuEST Ontario Public Health Libraries Association (OPHL) Primary Care Clinical Practice Guidelines Proquest Dissertations and Theses Database Theses Canada Portal Networked Digital Library of Theses and Dissertations New Zealand Guidelines Group National Library of Medicine National Guideline Clearinghouse GrayLIT Network Grey Source: A Selection of Web-based Resources in Grey Literature Grey Literature Bulletin (North West Health Library & Information Service, Liverpool, United Kingdom) Grey Literature Report [via New York Academy of Medicine website] NICHSR (National Information Center on Health Services Research & Health Care Technology) BC [British Columbia] EOHRN Grey Literature Wiki / Healthcare Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection/extraction Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative papers will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Potential conflict(s) of interest There are no conflicts of interest involved in this systematic review.

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