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SUMMARY 17 Attention to implementation and evaluation needs to be factored into the development process at an early stage. The Forum can underscore its intent to examine critically and improve its program and products in at least three ways. First, it should ask its expert panels for feedback on the strengths and weaknesses of the procedures followed. Second, it should pretest (or arrange for the pretesting of) all guidelines developed under its aegis. This can be done on a pilot basis in a real delivery setting, on a set of prototypical cases, or through both methods. Third, it should try to evaluate the effectiveness of intermediate actions (for example, formatting, dissemination, incentives) that are necessary if guidelines are to have their intended effects on health practices, outcomes, and costs. Each of these steps can be part of a learning process for the Forum and others. NEXT STEPS FOR THE INSTITUTE OF MEDICINE In May 1990, a new IOM committee began an 18-month study of the development, implementation, evaluation, and revision of clinical practice guidelines. Many of the issues raised in this report will be examined in depth during this second project, which is supported by the John A. Hartford Foundation, Inc., and the Public Health Service. In preparing its report and recommendations, the new committee will â¢ describe existing initiatives to develop, implement, and evaluate practice guidelines; â¢ identify the strengths and limitations of these efforts in light of the objectives and concerns of specific interest groups and society in general; â¢ describe different models of public and private action that might serve as prototypes for better structuring activities related to guidelines; â¢ analyze and assess the strengths, weaknesses, uncertainties, and trade-offs of different models in responding to identified problems and objectives; and â¢ propose a framework for better structuring the development, implementation, evaluation, and revision of practice guidelines. In addition, the new committee will propose a practical methodology for AHCPR and others to employ in assessing guidelines before recommending or using them. It will focus on how the guidelines were developed, their scientific basis, their relevance to clinical practice, their clarity, and other characteristics. Such initial assessments will not substitute for later evaluations by government and others of the impact of a set of guidelines. The committee's recommendations will cover both government and private activities, and its report will identify legislative, management, and