Clinical guidelines can lead to improved health care, but many guidelines are not effectively implemented. We examine what is involved in implementing guidelines and the evidence about the commonest and most effective methods for doing this, illustrated with clinical examples from paediatric practice where possible. Although the evidence for what works is incomplete, it provides some important pointers for clinicians who are nowadays faced with numerous guidelines.

BACKGROUND

Clinical practice guidelines are systematically developed statements which assist clinicians and patients in making decisions about the appropriate management of specific conditions and situations with the aim of improving the quality of health care.¹ They provide guidance or advice, rather than instructions, and are aids to and not substitutes for clinical judgment. Ideally they are evidence-based, but some may be based on clinical consensus.

There is a strong expectation that well-developed clinical guidelines will contribute to improved standards of clinical practice and outcomes. However the literature abounds with examples of guidelines not being fully or effectively implemented.^2–5 The time and resources devoted to guideline development and their potential impact on health care are then wasted. Implementation is not just a “brief interlude between a bright idea and opening the door for service”;⁶ it is a process not an event. There has been extensive research on guideline implementation which shows that this process is complex but the evidence about what works remains incomplete.⁷

A central directive alone does not lead to the widespread implementation of even evidence-based health care. In 2005 the Chief Executive of the National Institute for Health and Clinical Excellence (NICE) acknowledged that more needed to be done to secure full implementation of its guidelines.⁸ A number of national organisations that develop and circulate guidelines now issue outline guidance on implementation, for example NICE, SIGN …