Table 1

Clinical recommendation implementation phases

PhaseDescriptionPracticalities
1. PlanningThe implementation plan is reflected in a protocol that includes the following headings:

  • Background

  • Objectives

  • Implementation team

  • Contact and involved stakeholders

  • Milestones

  • Budget

  • Evaluation plan

  • Templates

  • Abundance of examples on the internet

2. Analysis of the contextIt should identify and describe at a minimum:

  • the care level/s and their relationships (from policies to hospital and public), interactions, mediators or determinants (eg, human and economic resources)

  • the organisational culture and climate

  • the teams to be involved in the implementation process

  • the human, material, economic and time resources available

  • the information systems

Narrative review based on interviews with local stakeholders and organisational data.
An analysis can be developed by each country or region and then be reviewed:

  • with each set of recommendations, that may require specific items

  • periodically

3. Identification of barriers and facilitatorsThese should reflect factors related to:

  • health professionals

  • social context (including patients)

  • organisational context

  • the recommendations itself

Use brainstorming, Delphi, nominal or focus groups, qualitative interviews, communities of practice or surveys (qualitative research techniques).
4. Design of strategiesThese can be tools, actions or activities.
Will imply economic, organisational or regulatory aspects.
The focus can be on clinicians, health professionals or patients.		Examples are leaflets, courses, clinical sessions, local consensus documents, changes in regulation, recruitment of health professionals, checklists, standards of care, decision rules or algorithms in electronic medical records, protocols, clinical pathways, etc.
5. EvaluationIt implies the definition of quality indicators. These include:

  • what to measure

  • how to measure it

  • sources and timing

Whenever possible, use quality indicators already developed in rheumatology.
6. ReviewEvaluation of the implementation process and related decisions.Periodical meetings of the implementation team to check on plan and quality indicators.