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IMPLEMENTATION AND EVALUATION 82 are undertaken by the same or different bodies. Of the precepts listed above, those relating to clinical specificity, clarity, and data recording can be particularly useful in assisting the move from guidelines for practitioners to criteria for assessing health care practice. To say that implementation needs to be considered as guidelines are developed is not to imply that every step and detail can be or needs to be foreseen. That kind of foresight is impossible. Moreover, just as there is no "one best way" yet identified or demonstrated to develop guidelines, neither is there one best way to implement them. Pluralism in both phases is likely to be the norm for the present. PLANNING FOR IMPLEMENTATION Clearly, successful implementation will depend on many factors in addition to the quality and credibility of the guidelines and their design process. Among those factors are (1) the funding for dissemination and other implementation activities; (2) the incentives and supports for the guidelines to be used by practitioners, health plans, and others; (3) the accessibility, scope, accuracy, and timeliness of a variety of intra- and interorganizational information systems; and (4) the ability of multiple parties to plan and execute the various steps needed to implement guidelines. Compared with the processes of designing guidelines, the processes of implementation tend to be more diffuse. The time horizon extends beyond the near future, the number of involved parties multiplies, local circumstances become more important, responsibilities blur, and actions become more difficult to track. These conditions make it more difficult to specify attributes of an implementation process in the way Chapter 3 specified the attributes of guidelines. Nonetheless, some of the factors that need to be considered in making implementation decisions can be articulated as noted below. â¢ The particular objectives to be served by the implementation process. Examples: rapidly informing practitioners of new guidelines that depart significantly from previous guidelines; providing immediate and continuously available assistance to practitioners as they diagnose or treat particular patients; educating consumers about the use of screening services (Avorn and Somerai, 1983; Lundberg, 1989; Somerai and Avorn, 1990). â¢ The expected effectiveness of alternative strategies in achieving the objectives in question. Examples: the impact of direct mail notification compared with publication in a journal; the accessibility of an interactive computer system versus printed instructions (Jacoby and Clarke, 1986). â¢ The cost of alternative strategies in relation to the expected benefit and the available resources. Examples: the cost of a press conference versus