Evidence-based implementation of evidence-based medicine.

BACKGROUND: The slow and haphazard process of translating research findings into clinical practice compromises the potential benefits of clinical research. Most quality improvement (QI) initiatives are based on the beliefs of decision makers rather than on the growing theoretical and empirical knowledge about organizational and provider behavior change. If future QI activities are to improve the translation of evidence into practice, they should be based on an understanding of the different models and strategies for implementing research evidence and the evidence base supporting their use. Evidence-based medicine should be complemented by evidence-based implementation. THE EVIDENCE FOR DIFFERENT STRATEGIES OF IMPLEMENTING CHANGE: A general framework for changing practice based on theoretical perspectives and research evidence considers a variety of theoretical approaches and their contribution to an understanding of provider behavior change. The framework summarizes evidence from systematic reviews of provider behavior change, which suggest the potential of several dissemination and implementation strategies that are effective under certain conditions. Passive dissemination approaches are largely ineffective; specific strategies to implement research-based recommendations appear to be necessary to ensure practice change. Multifaceted interventions that address specific barriers to change are more likely to lead to changes in practice. PRACTICAL, FIVE-STAGE FRAMEWORK: A practical, five-stage framework for changing practice, which is illustrated with experiences from a comprehensive program on implementing evidence-based clinical guidelines in primary care, includes development of a concrete proposal for change; analysis of the target setting and group to identify obstacles to change; linking interventions to needs, facilitators, and obstacles to change; development of an implementation plan; and monitoring progress with implementation.