Implementing Guidelines
Disseminate Policies and Guidelines at National Level
Dissemination of the guidelines at national level can begin by a variety of mechanisms. In many countries, dignitaries launch the new guidelines at a large, formal meeting attended by a diverse audience of politicians, healthcare professionals, consumers and the media. This event has the added benefit of increasing the public's awareness of the content, purpose and significance of the guidelines. Additionally, more targeted channels of communication are often used specifically to inform decision-makers, healthcare providers, women's health advocates, community groups, preservice educators, clinical trainers and supervisors about the guidelines.
Indonesia Launches National Guidelines at Workshop Attended by over 100 Key Stakeholders
At a workshop held on 1 July 2000 before the POGI (Indonesia Association of Obstetricians and Gynecologists) Congress in Bali, Indonesia officially launched its National Resource Document for Maternal and Neonatal Health (NRD-MNH). One hundred stakeholders, including Ob/Gyn specialists, teaching faculty from medical and midwifery schools and MOH representatives attended the meeting and were introduced to the NRD-MNH as the new, officially endorsed standard for maternal and neonatal healthcare.
The 600-page NRD-MNH, written in Bahasa Indonesia, contains sections on the principles of safe motherhood, care in normal pregnancy and childbirth, care of complications in pregnancy and childbirth, and detailed guidance for a broad range of obstetric and midwifery procedures. The NRD drew heavily from the WHO resource document Managing Complications in Pregnancy and Childbirth.
The NRD-MNH will be distributed to all medical and midwifery schools and reproductive health training programs in Indonesia, and to healthcare delivery sites throughout the country. A pocket-sized edition to be distributed to all healthcare providers is being produced.
Preservice education and inservice training materials, consistent with the NRD-MNH, have been developed and are already being used for care of normal pregnancy, childbirth, the postpartum period and the newborn. |
Disseminate Policies and Guidelines to Regional and District Levels
Dissemination and promotion of the completed documents to regional and district levels are the next step in the implementation process. This does not happen just by sending the documents out; it requires strategic planning and the commitment of adequate human and financial resources at both national and peripheral levels. For this part of the process to be successful, the material must be distributed to, and understood by, all levels of critical users. At least one copy of the guidelines should be placed in each appropriate healthcare facility.
Kenya Pioneers Successful Strategy for Dissemination of Reproductive Health, Malaria Guidelines
The dissemination of the Kenyan National Guidelines for Diagnosis, Treatment and Prevention of Malaria in Pregnancy is based on the extremely successful dissemination of the Kenyan document Reproductive Health/Family Planning Policy Guidelines and Standards for Service Providers, recently evaluated by FHI. This dissemination strategy works within the decentralized training system to train providers to train others in the use of the guidelines. The strategy is implemented by use of an orientation package and job aid to train providers and prepare them to update fellow staff. These staff then use the same method to prepare their fellow staff members to use the guidelines, and so on. The strategy also provides for on-site supportive supervision. The method has had a positive impact on healthcare provider knowledge and practices, and has been endorsed by FHI as an excellent example of guidelines dissemination.
The National Guidelines for Diagnosis, Treatment and Prevention of Malaria in Pregnancy will be disseminated in the same way by JHPIEGO at the request of DFID. JHPIEGO has developed the orientation package and job aid, conducted a baseline test and facilitated "echo" orientations in two malaria endemic districts. JHPIEGO is also conducting supportive supervision and will evaluate the success of the venture. |
The dissemination process works most effectively when a variety of appropriate strategies are implemented either together or sequentially to ensure both adequate distribution and understanding of the guidelines. The method used to disseminate these documents to different cadres of healthcare providers and at different points in the healthcare delivery system varies according to the cadre and level of the system targeted. It may involve creative dissemination techniques such as radio dramas, workshops, fliers that highlight important aspects of the guidelines, the Internet, hotlines for questions and problem solving, audio cassettes for distance learning and updates, posters and logos promoting sites that use the guidelines, and modeling by respected colleagues. Other methods include incorporating the materials into workshops, training programs, service manuals, job aids, supervision and monitoring tools, and client materials.
The materials used for dissemination must be easily understood and readily accessible to the healthcare providers who will use them and, as appropriate, to the communities that will benefit from them. They should reflect what is written in the guidelines in a way that best resonates with the intended target audience. The method of dissemination will certainly vary according to the end user, but ensuring that 100 percent of intended users receive and understand the documents is key to the success of the guidelines.
| Honduras Implements Guidelines on Hypertensive Disorders at Two Hospitals by Use of Checklist
In Honduras, two guidelines documents—one on norms for managing obstetric complications at the facility level and the other on norms and procedures for integrated care for women—were published in 1999. An assessment by the MNH Program at Hospital Mario Catarino Rivas and Hospital Escuela during the same year revealed high levels of maternal mortality and little adherence to the standards of care represented by the guidelines documents. In fact, the documents had not yet been disseminated widely and some key decision-makers had not participated in their development.Consequently, healthcare providers resisted using the guidelines as the basis for care provision.
The MNH Program began a project to operationalize the standards of care at the two hospitals, working closely with key influential personnel from the hospitals' obstetrics/gynecology departments. They developed a "verification list" for care for hypertensive disorders, the first standard to be addressed. This tool, which takes the form of a checklist, can be used for teaching healthcare providers how to manage patients with hypertension and for verifying that complete and appropriate care has been given to them. In effect, it serves as a service delivery guideline for a specific complication. A study is now underway at the two hospitals to determine whether implementation of the guidelines and utilization of the checklists make a difference in the quality of care provided for hypertensive disorders. If the results of the study show such a difference, additional standards of care will be addressed. |
Ensure Systems Are in Place to Support Quality Provision of Care
For national policy and guidelines to have an impact on healthcare provision, systems that support providers and help them to do their jobs effectively also have to be strengthened. These systems sustain implementation of the guidelines, and in many cases the guidelines help to sustain and strengthen the systems. National- and supervisory-level personnel should not expect standards to be consistently attained if the support systems for healthcare delivery are not constantly addressed. And each of these systems requires guidelines that are consistent with the national goals.
Human resource systems for deployment, retention and motivation of personnel, for example, must be in place so that there are sufficient numbers of the appropriate cadres of healthcare providers to give the high quality care defined by the guidelines. Training systems in both the preservice and inservice arenas also must support the implementation of the guidelines. Conversely, implementation of the guidelines is strengthened when personnel are trained and acquire the knowledge and skills they need to provide care that meets the new standards. Similarly, effective supervision systems both affect and are affected by implementation of the guidelines. Supervisors play a crucial role in facilitating the use of the guidelines by healthcare providers in their care provision, and the guidelines support supervisors in introducing and gaining acceptance for essential care practices. And systems for supplies and logistics, referral and monitoring and evaluation also must be strengthened to support guidelines implementation. The various systems involved and the changes that need to take place are discussed more fully in the next section.
Motivate Providers and Ensure That They Have Skills
When dissemination is complete, healthcare providers should be implementing the guidelines as part of their daily practice. But for this to happen, it is critical that providers be motivated to follow the guidelines and be trained in their use. Changing attitudes and behavior is known to be a difficult and challenging process, but it must be accomplished if healthcare providers' performance is to reflect the standards set out in the guidelines. Having a clear strategy for behavior change from the beginning, and then applying it consistently, is the approach most likely to lead to adherence.
Motivating and supporting providers are key to facilitating their adherence to the guidelines. Motivational programs such as orientation and training activities are designed to help providers achieve complete understanding of what is in the guidelines and how they should be used. This understanding encourages provider ownership—an important aspect of adherence. A sense of ownership gives providers the confidence to problem-solve and adapt guidelines to their needs. Concrete tools and tips that can be used by providers on a day-to-day basis also improve providers' motivation to adhere to the guidelines.
| Guatemala Uses Assessment Tool to Motivate Healthcare Services to Implement Guidelines
The MOH in Guatemala worked closely with the MNH Program to operationalize existing national guidelines and global standards by developing assessment tools that contain objective, verifiable criteria as well as incorporate provider perspectives and client needs and expectations. Through a participatory, inclusive process involving the MOH, healthcare institutions and the MNH Program, assessment tools for various technical areas of maternal and newborn healthcare provision were developed that list sentinel quality criteria for each area. Tools specific to each level of the healthcare system—health post, health center, community maternity and district hospital—have been developed. A MOH quality team performs the assessment using the tool, noting when and why particular criteria are not being met. The assessment allows an objective score (e.g., the number of criteria that a healthcare site has successfully met) to be calculated. By looking at the gaps in performance, the team can conduct a cause analysis and determine the appropriate interventions to address those gaps. After the appropriate interventions have been implemented, the assessment tools can again be utilized to determine changes in performance and quality. This assessment has been found to be a motivating force for healthcare providers to improve the quality of care they give, and has become part of the national process of accreditation. |
Inservice training courses will almost certainly be needed to equip current providers with the new skills set out in the guidelines. If there is a large number of providers to be trained, or a large number of skills in which they need training, this can be an enormous and costly undertaking. Modern learning methods, focused, competency-based training, distance learning techniques and computer-assisted instruction are ways in which some or all of the new skills can be taught in the most cost-effective manner. A fuller discussion of inservice training is found in the next section.
| East and Southern Africa Develops Regional Trainers to Ensure Implementation of Guidelines
To address the need for clinical experts in maternal and newborn healthcare, the MNH Program is developing a core group of faculty and trainers in three regions—Africa, Asia and Latin America. East and Southern Africa is the first region where activities under this initiative have taken place. Beginning in Uganda in October 2000, 22 midwife and physician clinicians from seven African countries were updated in evidence-based maternal and newborn healthcare practices and participated in clinical skills standardization.
The clinical portion of the training program is based on two of the international resource documents recently developed by WHO and JHPIEGO: Managing Complications in Pregnancy and Childbirth and Basic Maternal and Newborn Care. Topics addressed included antenatal care, including birth preparedness and complication readiness; malaria and anemia; hypertensive disorders; bleeding; nutrition and micronutrients; HIV; care during labor, delivery and the immediate postpartum; infection prevention; unsatisfactory progress in labor; rapid assessment and management of shock; care of the normal newborn, managing low birth weight and sick newborns; and improving provider performance and the quality of maternal and neonatal care. Training was conducted using prototypic presentation materials that are based on the best practices and the latest evidence and research in the field of maternal and neonatal healthcare.
The training process extends over a 12- to 18-month period, and includes a knowledge update, clinical skills standardization and training in clinical training skills, as well as a practicum. On completion of their training, participants will be able to serve as technical experts and pre- and inservice training resources for organizations and institutions throughout the African Region working to improve the quality of maternal and newborn healthcare services. |
Ensure Involvement of the Community
Both healthcare providers and clients must work together to make sure that standards of care are met. Community members and leaders have a vital role to play, both in developing and implementing guidelines, as part of their greater responsibilities to ensure and support healthcare.
Representative community leaders generally sit on safe motherhood committees and participate actively in the development of guidelines, particularly policy guidelines. It is important for communities to be involved in the guidelines development so that they can represent to the ministry of health the perceived needs of their respective communities. Unless these perceived needs are addressed in the adaptation of national guidelines, the community is unlikely to embrace all the services to be provided.
Communities also need to be involved in the implementation of the guidelines. A vital part of the implementation process is to inform
community members about when, where and how to access maternal and neonatal healthcare services. Women, their families and their communities need to develop new, higher expectations of what they have a right to receive from healthcare providers. In their action plans, therefore, implementers will need to include information, education and communication activities about services available to the communities they serve. These might include workshops, role plays, radio messages, newspaper articles, fliers, posters and other community-oriented activities. Providers, for their part, need to know methods of behavior change communication to improve their capacity to deliver appropriate messages and motivate communities. In this way, both providers and clients work together to ensure that standards of care are respected.
With health sector reform taking place in many countries, the community is becoming more actively engaged in the management of health facilities. Committees made up of both healthcare staff and community members are frequently used to develop strategies for putting guidelines into practice. This collaboration furthers acceptance by:
- giving the facility staff the opportunity to understand the community's perspective,
- giving the community the opportunity to understand constraints, and
- promoting community responsibility and support for the facility and its own health.
Community members involved in guiding or managing health facilities need to be made fully aware of the changes involved in improving the quality of maternal and neonatal healthcare services. Those members of the community with direct managerial responsibility should also know what concrete changes will have to take place within the facility (infrastructure, equipment, supplies, logistics, etc.) to implement the guidelines effectively.
It may not be possible to implement some parts of the guidelines at the healthcare service level alone. The healthcare system, for example, may not be capable of ensuring transport of a woman with complications to a primary healthcare facility or to a referral center. Communities, if appropriately mobilized, can take on this responsibility, either ensuring the transport itself, or creating a revolving community fund to pay for transport when it is required.
Communities are also increasingly included in monitoring and evaluating healthcare services. In many communities, community members themselves take the lead in assessing client satisfaction with services delivered. The results of their assessment are then fed back through the system, so that healthcare providers can adjust services to make them more client-friendly.
