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1.  Supported local implementation of clinical guidelines in psychiatry: a two-year follow-up 
Background
The gap between evidence-based guidelines for clinical care and their use in medical settings is well recognized and widespread. Only a few implementation studies of psychiatric guidelines have been carried out, and there is a lack of studies on their long-term effects.
The aim of this study was to measure compliance to clinical guidelines for treatment of patients with depression and patients with suicidal behaviours, two years after an actively supported implementation.
Methods
Six psychiatric clinics in Stockholm, Sweden, participated in an implementation of the guidelines. The guidelines were actively implemented at four of them, and the other two only received the guidelines and served as controls. The implementation activities included local implementation teams, seminars, regular feedback, and academic outreach visits. Compliance to guidelines was measured using quality indicators derived from the guidelines. At baseline, measurements of quality indicators, part of the guidelines, were abstracted from medical records in order to analyze the gap between clinical guidelines and current practice. On the basis of this, a series of seminars was conducted to introduce the guidelines according to local needs. Local multidisciplinary teams were established to monitor the process. Data collection took place after 6, 12, and 24 months and a total of 2,165 patient records were included in the study.
Results
The documentation of the quality indicators improved from baseline in the four clinics with an active implementation, whereas there were no changes, or a decline, in the two control clinics. The increase was recorded at six months, and persisted over 12 and 24 months.
Conclusions
Compliance to the guidelines increased after active implementation and was sustained over the two-year follow-up. These results indicate that active local implementation of clinical guidelines involving clinicians can change behaviour and maintain compliance.
doi:10.1186/1748-5908-5-4
PMCID: PMC2832625  PMID: 20181013
2.  Implementing clinical guidelines in psychiatry: a qualitative study of perceived facilitators and barriers 
BMC Psychiatry  2010;10:8.
Background
Translating scientific evidence into daily practice is complex. Clinical guidelines can improve health care delivery, but there are a number of challenges in guideline adoption and implementation. Factors influencing the effective implementation of guidelines remain poorly understood. Understanding of barriers and facilitators is important for development of effective implementation strategies. The aim of this study was to determine perceived facilitators and barriers to guideline implementation and clinical compliance to guidelines for depression in psychiatric care.
Methods
This qualitative study was conducted at two psychiatric clinics in Stockholm, Sweden. The implementation activities at one of the clinics included local implementation teams, seminars, regular feedback and academic detailing. The other clinic served as a control and only received guidelines by post. Data were collected from three focus groups and 28 individual, semi-structured interviews. Content analysis was used to identify themes emerging from the interview data.
Results
The identified barriers to, and facilitators of, the implementation of guidelines could be classified into three major categories: (1) organizational resources, (2) health care professionals' individual characteristics and (3) perception of guidelines and implementation strategies. The practitioners in the implementation team and at control clinics differed in three main areas: (1) concerns about control over professional practice, (2) beliefs about evidence-based practice and (3) suspicions about financial motives for guideline introduction.
Conclusions
Identifying the barriers to, and facilitators of, the adoption of recommendations is an important way of achieving efficient implementation strategies. The findings of this study suggest that the adoption of guidelines may be improved if local health professionals actively participate in an ongoing implementation process and identify efficient strategies to overcome barriers on an organizational and individual level. Getting evidence into practice and implementing clinical guidelines are dependent upon more than practitioners' motivation. There are factors in the local context, e.g. culture and leadership, evaluation, feedback on performance and facilitation, -that are likely to be equally influential.
doi:10.1186/1471-244X-10-8
PMCID: PMC2822755  PMID: 20089141
3.  An approach to measure compliance to clinical guidelines in psychiatric care 
BMC Psychiatry  2008;8:64.
Background
The aim of this study was to measure six months compliance to Swedish clinical guidelines in psychiatric care after an active supported implementation process, using structured measures derived from the guidelines.
Methods
In this observational study four psychiatric clinics each participated in active implementation of the clinical guidelines for the assessment and treatment of depression and guidelines for assessment and treatment of patients with suicidal behaviours developed by The Stockholm Medical Advisory Board for Psychiatry. The implementation programme included seminars, local implementation teams, regular feedback and academic visits. Additionally two clinics only received the guidelines and served as controls. Compliance to guidelines was measured using indicators, which operationalised requirements of preferred clinical practice. 725 patient records were included, 365 before the implementation and 360 six months after.
Results
Analyses of indicators registered showed that the actively implementing clinics significantly improved their compliance to the guidelines. The total score differed significantly between implementation clinics and control clinics for management of depression (mean scores 9.5 (1.3) versus 5.0 (1.5), p < 0.001) as well as for the management of suicide (mean scores 8.1 (2.3) versus 4.5 (1.9), p < 0.001). No changes were found in the control clinics and only one of the OR was significant.
Conclusion
Compliance to clinical guidelines measured by process indicators of required clinical practice was enhanced by an active implementation.
doi:10.1186/1471-244X-8-64
PMCID: PMC2525637  PMID: 18657263

Results 1-3 (3)