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BA Sorofman, The University of Iowa College of Pharmacy; T Tripp-Reimer, The University of Iowa College of Nursing; JE DeWitt, Drake University College of Pharmacy; BJ BootsMiller, Program in Health Services Research, Iowa City VAMC; MM Adams, The University of Iowa College of Medicine, Department of Internal Medicine; BN Doebbeling, Program in Health Services Research, Iowa City VAMC and The University of Iowa College of Medicine, Department of Internal Medicine

Objectives: Clinical practice guidelines (CPGs) improve patient outcomes and decrease resource utilization. In VA, a key performance indicator is the External Peer Review Program (EPRP), which provides documentation data relative to CPGs. The best approach to integration of CPGs into health care systems is not well understood. The purpose of this research was to identify factors at the provider and facility level associated with effective CPG implementation at VA acute care facilities. The specific aims were to identify and categorize facilitators and barriers influencing the effectiveness of CPG implementation.

Methods: The research design was a naturalistic investigation of personnel in a national sample of acute care hospitals using focus groups. The sample was selected using a systematic process to identify maximal differences in geographic location, quality indicator data, hospital bed size, medical school affiliation, population age, the proportion of minority veterans served, and VISN. Thirty hospitals were selected and prioritized to obtain maximum heterogeneity; 50 focus groups were conducted at 18 facilities nationally, representing 11 different VISNs. At most institutions, three focus groups representing different stakeholder views of CPG implementation were conducted: administrators/managers, primary care providers (physicians, ARNPs, and PAs), and clinicians (e.g., nurses, pharmacists, and dieticians). A focus group guide structured discussions with each group and explored the context, history, and experience of CPGs in the facility in general, and smoking and diabetes guidelines in particular. Perceived facilitators and barriers from each group's perspective were elicited. Group interviews were taped, transcribed, and coded using computer-assisted text analysis software. Coding identified and labeled participant comments as facilitating and/or impeding implementation, and as being associated with organizational, implementation, practice, practitioner, or guideline characteristics. Categories were sorted and crosscutting themes and recurring patterns were identified.

Results: Facilitators and barriers to effective CPG implementation were identified. Major facilitators included administrative commitment (assignment of personnel, time, and computerized resources) and clinical role restructuring. Individual facilitators included assigned and informal guideline "champions." Guideline-related facilitators included simplicity, clarity, and face validity of the guidelines. Practice prompts, audit, and feedback were significant facilitators to documenting performance indicators. Barriers included lack of administrative commitment due to facility priorities and lack of resources (e.g., specialty providers, computer support, and time) to achieve the mandated activities. Guidelines were often seen as complex, rigid and impractical in the clinical setting. Many individuals in the focus groups reported never having seen a CPG.

Conclusions: Three areas of CPG implementation must be explored to improve use at the local level. At the national level, CPGs must be more accessible and each guideline should come with a suggested process for distribution and implementation within each VISN and facility. At the local and VISN level, guidelines should be evaluated for clinical relevance to the local practice standards and processes. Finally, CPGs should be distilled, tailored to fit, and integrated into local practices.

Impact: Multi-site VA personnel focus groups provided key elements for a forthcoming systematic national survey of CPG use. Data are being used to propose changes in CPG implementation processes at national and local levels.