ized clinical practice guidelines may not be successful in addressing the threats of emerging infections.

REALITIES OF IMPLEMENTING GUIDELINES

Presented by Nora Morris, M.A.

Assistant Director/Senior Analyst, Healthcare Education and Research Foundation, Inc.

The implementation of standardized clinical practice guidelines in managed care systems is a difficult process that requires communitywide efforts, including participation from the purchasers of health care plans. Development and adoption of clinical practice guidelines will involve changes in the individual and organizational behaviors of physicians, nurses, health care administrators, patients, and individual health care facilities. Health care providers presented with clinical practice guidelines must consider them in light of the financial incentives of the managed care organization, professional incentives and culture, personal and professional beliefs and experiences, and what they consider to be in the best interest of the patient. Patients on the receiving end also bring to their treatment a health history, and personal beliefs and experiences. Broad participation in the development of guidelines will ensure that barriers to adoption are identified early.

An example of the successful implementation of clinical practice guidelines can be found in the managed care systems in the St. Paul-Minneapolis area. Since the early 1990s, managed care organizations in that region have worked together to institute standardized clinical practice guidelines. To accomplish this goal, participating organizations first targeted the audiences for such guidelines: physicians, nurses, health care administrators, and patients. Second, potential barriers to implementation were identified: knowledge and skills deficits and resource and organizational shortfalls. It was not until these issues were addressed that efforts were made to complete and implement the guidelines.

The barriers to implementation of standardized clinical practice guidelines may be found at many levels within a managed care setting. Knowledge and skills deficits have the ability to affect the decisions of all participants. For example, primary care physicians treating a patient with AIDS and lacking access to the most current data about courses of therapy may be daunted by sophisticated treatment guidelines. At the patient level, the degree of family support that a patient receives is a contributing factor to the acceptance or rejection of standardized guidelines, as is the degree of community and financial support available. These factors combine to influence a patient's decision about seeking and adhering to therapy. At the organizational level, ongoing conflicts within an organization may prevent members from learning about and adhering to proposed guidelines. This type of barrier can be more difficult to address since it involves changing the behaviors of many people simultaneously. Full imple



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