Clinical practice guideline implementation strategy patterns in veterans affairs primary care clinics

Background. The Department of Veterans Affairs (VA) mandated the system-wide implementation of clinical practice guidelines (CPGs) in the mid-1990s, arming all facilities with basic resources to facilitate implementation; despite this resource allocation, significant variability still exists across VA facilities in implementation success. Objective. This study compares CPG implementation strategy patterns used by high and low performing primary care clinics in the VA. Research Design. Descriptive, cross-sectional study of a purposeful sample of six Veterans Affairs Medical Centers (VAMCs) with high and low performance on six CPGs. Subjects. One hundred and two employees ( management, quality improvement, clinic personnel) involved with guideline implementation at each VAMC primary care clinic. Measures. Participants reported specific strategies used by their facility to implement guidelines in 1-hour semi-structured interviews. Facilities were classified as high or low performers based on their guideline adherence scores calculated through independently conducted chart reviews. Findings. High performing facilities (HPFs) ( a) invested significantly in the implementation of the electronic medical record and locally adapting it to provider needs, (b) invested dedicated resources to guideline-related initiatives, and ( c) exhibited a clear direction in their strategy choices. Low performing facilities exhibited ( a) earlier stages of development for their electronic medical record, ( b) reliance on preexisting resources for guideline implementation, with little local adaptation, and ( c) no clear direction in their strategy choices. Conclusion. A multifaceted, yet targeted, strategic approach to guideline implementation emphasizing dedicated resources and local adaptation may result in more successful implementation and higher guideline adherence than relying on standardized resources and taxing preexisting channels.