ied local circumstances and priorities complicate decision making and generate conflicting incentives; and actions become more difficult to track. These conditions make it hard to specify attributes of good implementation processes in the way that the first IOM report specified the attributes of good guidelines. They also help explain why efforts to implement guidelines and related kinds of recommendations have met with limited success to date (Eisenberg, 1986; Schroeder, 1987; Lomas et al., 1989, 1991).

GUIDELINES AND THE REAL WORLD

One challenging current reality surrounding the implementation of guidelines is that many potential users are either unaware of guidelines or view them as being of marginal utility in their day-to-day work. Hardly unique is the urban community hospital staff who responded to the committee's inquiry about a site visit to discuss the use of guidelines by saying that there was really nothing related to guidelines going on at their institution.

For practitioners, guidelines are just one element in a range of practical and interpersonal challenges of patient care and practice management. Further, the perceived salience of formal guidelines may be lessened by the likely tendency of clinicians to consider accepted, internalized guidelines as something other than guidelines; for example, schedules for well-baby care may be so deeply ingrained that they are simply no longer regarded as guidelines. Some practitioners may well resist guidelines as threats to their autonomy even when the source is a professional organization.

For senior health care executives, too, other issues come first: patients, staff, payers, suppliers, competitors, institutional survival-although not necessarily in that order. When these executives frame a vision of their institutions for the future and a management strategy to achieve that vision, guidelines are not likely to appear in mission statements and five-year plans.

For patients and their families, guidelines are even more remote. Few laypersons will know about formal efforts to develop clinical practice guidelines; even fewer will know of their initial products or be able to use them directly. The focus of guidelines for patients, therefore, is likely to be educational—for example, handbooks or brochures about proper care for a given ailment, appropriate preventive regimens, or when to seek professional health care and when to manage one's own care.

Keeping an overview of implementation reasonably compact but illuminating is difficult, given the scope and variety of implementation efforts, on the one hand, and the lack of systematic literature about the topic, on the other. Compared with the development of guidelines, implementation is not only harder to do but more difficult to describe and analyze. The complexity of the implementation task just in terms of potential users may be illustrated (perhaps overdramatically) by estimated numbers of those who may



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