Before, during and after the BPG Order SetTM implementation, it is important to monitor utilization, evaluate the impact of the change in practice, and ensure mechanisms are in place to promote sustainability.
Monitoring
Many factors influence the degree to which end-user adoption is realized. Therefore, ongoing monitoring of end-user adoption of the BPG Order Set is a critical activity that promotes long-term adherence to evidence-based practice. Adoption may be affected by structures and processes within the practice setting. When this occurs, end users may choose to adopt some or none of the interventions in the BPG Order Set. The latter would be considered a failed implementation. It is possible for both adoption or failed implementations to be limited to an individual, unit/department/program or the organization as a whole.1
The planned activities for ongoing monitoring of adoption should be implemented during this phase of the project to:
- Determine the extent to which the BPG Order Set has been accepted and integrated within the end users’ daily workflow; and
- Ascertain whether the BPG Order Set was successful in changing clinical practice.
If the level of adoption is less than expected or desired, it is important to identify the underlying causes and develop strategies to mitigate any barriers and or modify the implementation strategies accordingly. If the level of adoption is satisfactory, mechanisms for monitoring sustained utilization (e.g., chart audits) should be implemented.1
Evaluation
The goal of evaluation is to understand the impact of implementing the guideline(s) using BPG Order Sets. The ongoing monitoring of adoption and the evaluation of the impact of the implementation are closely linked. It is difficult to interpret the impact without knowing the extent to which adoption has occurred. Since adoption can be impacted by multiple factors evaluation must occur at multiple levels: structure, process and outcome. Structural measures focus on impacts at the organizational level (e.g., policy that requires the practice change recommended in the guideline). Process measures evaluate impacts at the health-care provider level (e.g., screening for pressure injury risk on admission). Outcome measures assess impacts at the patient level (e.g., prevalence of pressure injuries).1
Prior to beginning the evaluation, it is important to determine whether ethics approval might be required. Ethics review is required for all research involving human subjects. Ethics review is typically not required for quality assurance and quality improvement initiatives or program evaluations. However, there are a few grey areas where the requirements are not clear cut. Organizations are strongly encouraged to obtain an ethics review if the results of the guideline implementation will be published.1
Sustainability
The sustainability plan developed earlier in the planning phase should be implemented during this phase of the project. This plan should include strategies for sustained adoption of the BPG Order Sets beyond the initial implementation phase. A sustainability plan is essential to ensure that the practice changes are fully integrated into the end users’ workflow processes.
Strategies for sustaining practice changes include:
- Collective vision by clinical and senior leaders that fosters a positive attitude toward evidence-based practices.
- Mechanisms that promote sustained adoption of the BPG Order Sets (e.g., chart audits, evaluation of process measures and using the data for ongoing quality improvement).
- Expectations for the utilization of the BPG Order Sets are embedded in organizational structures and processes (e.g., team/unit council meetings, new staff orientation procedures, performance appraisals).1
References
- Registered Nurses’ Association of Ontario. (2012). Toolkit: Implementation of best practice guidelines (2nd ed.). Toronto, ON: Author.