Implementing Change - It'S As Hard As It Looks

With increasing efforts to put evidence-based medicine into daily practice, it has become apparent that current ad hoc implementation strategies do not result in desired outcomes. There is a need to evaluate and further develop evidence-based implementation strategies that are effective and efficient. To begin this effort, the authors recognize the importance of integrating implementation into program development rather than treating it as an afterthought to be achieved through promotion and encouragement. Reviewing three empirical frameworks, derived from experience with continuous quality improvement (CQI) programs, guideline and practice change implementation, and disease management programs, the authors identify four key factors for successful program development and implementation. The four factors are: aligning the program with the strategic goals of the organization; obtaining active senior leadership commitment, including allocated resources; securing the appropriate infrastructure to facilitate integration of recommended actions into daily practice; and setting up systematic communications with all involved stakeholders. The authors reviewed randomized clinical trials that compared single and combined implementation approaches to determine whether experimental results would confirm the empirical findings. The results of these clinical trials demonstrated that when organizational commitment, in the form of allocating sufficient resources and/or providing a facilitating infrastructure, is lacking, programs are not successfully implemented. The studies did not explicitly evaluate the concept of strategic alignment of goals or communication strategies. Considering these findings, the authors wonder whether it is worthwhile to develop programs in settings that lack the major success factors, since they are likely to fail to be implemented widely. Before reaching this conclusion, they recommend more research to identify more clearly the nature of the success factors and their relative importance in achieving the desired outcomes of disease management programs.