The effect of provider- and workflow-focused strategies for guideline implementation on provider acceptance

BACKGROUND: The effective implementation of clinical practice guidelines (CPGs) depends critically on the extent to which the strategies that are deployed for implementing the guidelines promote provider acceptance of CPGs. Such implementation strategies can be classified into two types based on whether they primarily target providers (e.g., academic detailing, grand rounds presentations) or the work context (e.g., computer reminders, modifications to forms). This study investigated the independent and joint effects of these two types of implementation strategies on provider acceptance of CPGs. METHODS: Surveys were mailed to a national sample of providers (primary care physicians, physician assistants, nurses, and nurse practitioners) and quality managers selected from Veterans Affairs Medical Centers (VAMCs). A total of 2,438 providers and 242 quality managers from 123 VAMCs participated. Survey items measured implementation strategies and provider acceptance (e.g., guideline-related knowledge, attitudes, and adherence) for three sets of CPGs--chronic obstructive pulmonary disease, chronic heart failure, and major depressive disorder. The relationships between implementation strategy types and provider acceptance were tested using multi-level analytic models. RESULTS: For all three CPGs, provider acceptance increased with the number of implementation strategies of either type. Moreover, the number of workflow-focused strategies compensated (contributing more strongly to provider acceptance) when few provider-focused strategies were used. CONCLUSION: Provider acceptance of CPGs depends on the type of implementation strategies used. Implementation effectiveness can be improved by using both workflow-focused as well as provider-focused strategies.