Systematic reviews in various health care settings have demonstrated that different implementation interventions have varying effects. [1,2]. Most interventions to implement clinical guidelines focused on changing professional behaviour, but there is increasing awareness that factors related to the social, organisational and economical context can also be important determinants of guideline implementation. For instance, a recent study on the implementation of screening guidelines in ambulatory settings has confirmed the influence of a number of organisational factors, such as mission, capacity and professionalism. Despite increasing attention to organisational determinants of guideline implementation, research evidence on the relevance of specific factors is still limited. Insight into these factors is important as it can improve the effectiveness of implementation interventions by tailoring interventions to local circumstances. For example, different interventions may be more effective at academic hospitals than at community hospitals.
Most reviews on guideline implementation were conducted on implementation across settings, or implementation in primary care settings. The literature on guideline implementation in hospital settings has not yet been reviewed separately. Therefore, we reviewed the effect of different intervention strategies to implement clinical guidelines at hospitals, and explored the impact of specific organisational factors on the effectiveness of these interventions. Hospitals are complex organisational systems whose primary aim is to deliver clinical care to individual patients. Management theories on change and innovation were analysed to derive specific factors for this explorative study. We identified the following factors that moght modify the effects of interventions: sufficient management support, appropriate learning environment, functional differentiation and local consensus on the intended changes (figure (figure11).
Theories on leadership and on quality management have suggested that support for an innovation from hospital management has a positive impact on its adoption [7-9]. The impact of management support may be based on power, incentives or facilitation. Hospital managers may also act as role models by implementing the innovation. Thus we hypothesized that implementation interventions are more effective if the effort is clearly supported by the local leaders.
The learning environment comprises a second set of factors. The underlying mechanism is that the availability of knowledge in the organisation enhances the adoption of innovations. This is consistent with existing theory on organisational learning, which suggests that an organisation's capacity to learn as an organisation is a crucial feature. Teaching hospitals create a specific learning environment for trainers and trainees. Therefore we expected that implementation interventions are more effective in teaching hospitals than in non-teaching hospitals.
Functional differentiation is another factor that is expected to influence the uptake of new information or procedures in practice. A higher level of specialisation and a higher level of technical expertise in the organisation may enhance implementation. The level and diversity of knowledge may be larger in settings with a range of medical disciplines, in which there is involvement of consultants, other physicians and non-physician practitioners. We therefore hypothesized that higher functional differentiation is positively associated with the effectiveness of implementation interventions.
Finally, we expected that promoting ownership through local consensus about clinical guideline recommendations and implementation strategies may also be associated with better uptake. Organisational learning theory suggests that information gathering, shared perceptions of performance gaps and an experimental mind-set are important factors for learning in organisations. Specific group cultures at hospitals appear to be associated with patient outcomes. Theory on complex adaptive systems suggests that innovations should not be specified in detail in order to promote ownership and that 'muddling-through' should steer the guideline implementation process, while theory on adult learning adds that implementation should be tailored to each individual's learning needs. We hypothesized that guideline implementation interventions would be most effective when developed within a hospital rather than derived from sources outside a hospital.
This systematic literature review aimed to assess the effectiveness of implementation and quality improvement interventions in hospital settings and to test our hypotheses on the impact of organisational factors.