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IMPLEMENTATION AND EVALUATION 80 nor the Subcouncil has explicit responsibilities for program oversight, and it remains to be seen what their specific roles will be with respect to the program. 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, the Forum 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 by both methods, but it needs to be done. Third, the Forum 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. Guidelines Implementation The second implementation taskâthe focus of this chapterâinvolves taking a set of practice guidelines, once they have been developed, into the actual world of health care delivery. It is in such a sphere that guidelines will prove themselves as effective or ineffective interventions. Government Responsibilities for Implementing Guidelines OBRA 89 outlined certain responsibilities for AHCPR and the Forum that relate directly to the implementation of practice guidelines. The Forum was specifically directed to concern itself with formats of guidelines (for medical educators, consumers, practitioners, and medical review organizations) and with disseminating and otherwise making guidelines available. More generally, the legislation requires that the Secretary of Health and Human Services ''provide for the use of [the initial set of] guidelines. . .to improve the quality, effectiveness, and appropriateness of care provided under Title XVIII." This and other legislative language implies the involvement of other federal agencies such as the Health Care Financing Administration (HCFA) and the National Library of Medicine (NLM). Although nothing is said about the role of government as a direct provider of health care services, the health care systems administered by the Department of Defense, the Department of Veterans Affairs, and the Public Health Service clearly allow a government role in implementing guidelines in health care settings.
