decision making in everyday practice: conflicts between perceived patient needs and guidelines, the hassle factor that confronts physicians in implementing guidelines, financial incentives and disincentives facing physicians in private practice, and the exigencies of day-by-day management of patient care. Several important elements cut across settings of care: administrative decision making and follow-through; collaboration (or lack of it) across the main departments of an institutional provider; the role of top management; quality of care, quality assurance, and continuous quality improvement; risk management and liability; computer-based information and decision support systems; a myriad of elements relating to the local development, adaptation, and implementation of guidelines; and simple human error. External factors include the existence of conflicting guidelines, insurance benefit plans and coverage policies, requirements concerning preprocedure review, limited institutional or community resources, and local, state, and federal regulation.

Working models of the successful use of guidelines are not now abundant. Thus, opportunities to learn from one's peers, so common in other areas of health care management, seem to be rather scarce. This means that implementation is, in some respects, a challenge that must be met de novo by each health care organization. Until more practical experience with guidelines is available, discussions of implementation will necessarily be somewhat theoretical. The next two chapters consider how educational activities, information systems, and efforts to manage quality, costs, and liability may—in principle—support and be supported by guidelines for clinical practice.