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IMPLEMENTATION AND EVALUATION 88 hospitals, clinics, and similar delivery settings. Conceivably, these agencies could be laboratories for testing guidelines and alternative ways of implementing them. Provider Organizations Administrative processes to support the application of guidelines will vary depending on an organization's purposes, structure, and resources. For example, staff-model HMOs, independent practice associations (IPAs), and public clinics may differ in how they integrate the use of guidelines with ongoing organizational programs such as staff education and patient outreach. The type of targeted mammography screening guidelines and programs that a staff-model HMO with a stable membership can manage (Field, 1990) would seem to be of questionable feasibility for a clinic serving migrant workers. Similarly, organizations with more resources (for example, libraries, video centers, telephone hotlines, personal computers, and access to local and national computer information systems) will be able to facilitate the use of guidelines in ways that are out of reach for less resource- rich organizations. Some organizations may want to establish formal programs to encourage adherence to guidelines. Such programs might include (1) preparation of standard operating procedures for staff (for example, for checking anesthesia equipment), (2) contracting with practitioners based on their acceptance of selected guidelines, or (3) periodic feedback on how an individual practitioner's behavior compares with both peer practices and specific guidelines. These mechanisms can reinforce guidelines along several dimensions including validity, reliability, and credibility. Review Organizations Medical review criteria and other evaluation instruments, if properly developed and sensitively applied, can create incentives for adherence to practice guidelines. If poorly developed and insensitively applied, they can undermine support for practice guidelines. Fortunately, the processes of translating guidelines into review criteria and then applying them provide one opportunity for early identification and correction of omissions. The Forum may want to consider establishing early contact with the peer review and quality assurance communities to help ensure the best possible movement of guidelines into these applications. No one, however, should underestimate the challenges this movement entails. As discussed in Chapter 3, this committee's charge did not include recommendations on principles and techniques for translating guidelines into practice evaluation instruments. However, because review procedures have the potential either to support or undermine guidelines, the committee