Paper: Developing clinical guidelines - excellent set of papers

Here is a paper (series of three) from authors who are experts in this field. I've always been a bit ambivalent as to whether guidelines actually work - in terms of changing behaviour. I'm still not convinced but it's good to see a bit more work being done to identify the target audiences for guidelines as well as considering conflicts of interest etc.  Getting them right is a lot more complex than just collating what seems to be best practice, writing it up and then distributing them widely.

Oh, and the full text of the papers is free - that's nice. http://www.implementationscience.com/series/ClinPracGuidelines

Developing clinical practice guidelines

Edited by: Prof Martin Eccles, Dr Paul Shekelle 

Collection published: 4 July 2012

These articles describe the state of the art in developing clinical practice guidelines. As well as updating on established areas, such as evidence review and group composition, they also address contentious areas - conflicts of interest - and new and emerging topics including updating guidelines, dealing with co-morbidities and guideline implementability.

(Picture and text above is from the Implementation Science Webpage)

NEAR:Narrative Evaluation Action Research - Resource Guide

From "down under" we've got a great resource in the form of a toolkit, including all the background information and evidence, on how to gather healthcare stories that are part of an evaluation process.

It includes case studies (from Victoria, Australia) as comprehensive set of resources with guidance for their use.

You can download the document here (it does take a little while)

The list of resources below is from their Contents page:


"Resource A Initial Department of Human Services narrative guidelines 2002–03 ........ 30
Resource B Revised narrative guidelines 2003–2004 and 2004–2006........................ 31
Resource C Project information resource............................................................... 33
Resource D Annotated bibliography of useful readings ............................................ 38
Resource E An agency reflection on ‘first time’ narratives........................................ 44
Resource F Some questions to guide narrative evaluation ....................................... 47
Resource G What makes a good narrative? ........................................................... 49
Resource H A planner or checklist of questions for narrative action evaluation writers . 52
Resource I Extract – A practitioner reflects on the value of narrative action evaluation 54
Resource J Marjorie Oke and the hydrotherapy story (Vale)..................................... 55
Resource K Map of levels, voices and styles .......................................................... 69
Resource L The Northcote Hydrotherapy case study (extract CDIH collection 1st Edition
 Edition 1988) ............................................................................................... 58
Resource M When training your own trainers (DIY) to extend skills in writing narrative     
action evaluation............................................................................................... 64
Resource N Example of plain language description and consent form (ethics)............. 66
Resource O Supporting narrative evaluation in a community health setting................ 68"

Is there evidence for your quality improvement intervention?

Is there evidence for the interventions we're using to improve quality of services and to reduce costs? I suspect in many cases there isn't. Sometimes just doing something is better than nothing, though I do find it surprising that some organisations are strong at pushing a particular intervention, even though there are few (unpaid for) independent evaluations. And on the other hand, there are some well evidenced interventions that organisations don't want to use because they are appear old fashioned. Hmmm - we demand of healthcare professionals that they use the best evidenced methods - should we be demanding that of ourselves?

There's an excellent visualisation for the scientific evidence of dietary supplements. When I looked at this I wondered whether we could do something similar for the quality improvement interventions that are being used around the world?

In the meantime, using the SQUIRE Guidelines to write up your projects will go a long way to building up an evidence base of what works - and what doesn't.

eLearning 3: 5 Resources for effective online conferences

With the bans of travel and other cost reductions in place, eConferencing is on the up. Unfortunatley, this is iften paralled with a signficiant reduction in value for the participants. eConferencing is more than ticking the box that you've "run an event".

Let's look at what not to do in a video conference:



Other resources

• 19 tips for effective online conferences; from eLearning Technology
• http://onlinelibrary.wiley.com/doi/10.1002/stvr.411/pdf (I liked the lessons learned and tips for the future) PDF
• Guidelines for running online seminars
•  Online conference - a participant's perspective

Disseminating guidelines using MBTI Style

One of the eternal difficulties in the dissemination and application of clinical evidence is what I believe to be the " style gap".

Either they are researched and written so generically it is difficult for any individual or team to see how they apply to them. Or they are written so specifically that individuals and teams are so constrained to the detail and working out how they apply to themselves, they don't implement.

Different groups and organisations have developed their own ways round this problems. At a National or Regional level, boards and groups develop guidelines that are generic and then disseminate with a covering letter urging local adaptation of these guidelines. They know there will need to be local differences and contexts taken into account so they acknowledge this. This raises some questions for me:

• to what extent does turning the generic into the specific mean the intended benefits remain?
• are there different bits that can be adapted in different ways? Do the authors suggest how different bits can be adapted?
• what are the systemic links with other pathways, clinical areas etc that need to be taken into account?
• what are the contextual variables that are necessary for the generic guideline to be implemented (things like resources)?
• Where to start? Something practical?

For those guidelines which are so specific as to be overwhelming

• how do all these details scale up into themes and topics?
• what are the patterns and links to systems that will be useful to know about?
• which if the details are most important? Which ones can be left out and the main benefits are still reached?
• is there a specific order to implementation?
• how to the parts integrate with other systems like IT and HR?

I don't know the solution to this. What I do know is that many clinical and process guidelines are written in the MBTI (Myers Briggs Type Indicator) N/Intuitive style. This is the big picture, system and pattern way of seeing things. In contrast many of those required to implement these guidelines are more comfortable working with details (MBTI S/Sensing) and make sense easier of instructions if they are practical and specific. Sometimes the reverse is true - S's develop guidelines for N's to implement.

All the other parts of the MBTI styles could be a factor in the adoption of messages that change personal behaviour.

Perhaps one way round this is to use dissemination processes and content in a way which best suits the style of the potential adopters rather than the comfort of the authors.

Adoption of guidelines: trust?

A perennial issue on spread and adoption is how clinical guidelines are adopted - or not. There is an industry researching what happens, what might be useful intervention and what you can then do to increase the speed and amount of adoption.

My own rather accidental piece of "research" raised a new question for me: to what extent is trust both an enabler and disabler of the adoption process?

So I've been cooking. The real thing, with recipes. I spent the better part of a month working through many of the Women's Institute favourite 650 recipes. A trusted cookbook and mostly failsafe. What I found is it is incredibly difficult to follow a recipe down to all the details. The more I used recipes the more I found myself adapting them - to varying degrees of success.

Then I moved on to Nigella's Express cookbook. A week later I noticed I was slavishly adhering to every minute detail. Not like me at all. So what was going on here?

Nigella writes in the first person and the way recipes are written has engaged me in a new way. When a note in brackets suggests options, reassures you that she really did mean 250ml double cream or reinforces why this step is important, then it seems more trust in the process is repaid by more attention to detail in following instructions.

Many clinical guidelines are produced by committees. Yes they may be great sets of instructions, however, are they written as mechanisms that attract trust? I wonder what would happen if a trusted peer rewrite guidelines in a personal language and tone. Would they be adopted more quickly?

I did think maybe this is about personal choice of style of communication. Maybe. And should that detract from finding some novel ways to encourage the adoption of guidelines?