National Guidelines Update Process: Key Steps

1. National Guidelines Update Process:Key Steps

2. Objectives • Identify guideline components • Share best practices in the guidelines development and dissemination

3. What are Guidelines ? Guidelines may include several component: • Service delivery policies • Service delivery standards • Clinical guidelines and protocols • Clinical management plans

4. Why Develop National Guidelines ? Guidelines are key to improving access to high quality service delivery: • Provide the foundation on which high quality services can be built or strengthened • Reduce medical and access barriers • Standardize provider practices • Guide the content for inservice training and preservice education programs • Guide supervisory and management systems • Provide standards for monitoring and evaluating quality of care

5. Steps in the Guidelines Process “MAQ: From Guidelines…to Action Conference”, May 1998

6. Step 1: Establish Need • Indonesia Example • Variety of Service Delivery Guidelines • National Government • Professional Organizations • Project Specific Documents • NGO Materials • Confusion among providers and managers • Review data • Collect existing documentation • National Level • Service Delivery Points • Conduct needs assessment • Include compliance issues

7. Step 2: Ensure Broad Scope andCommitment • Indonesia Example • STARH Program Identified Key/Influential Stakeholder – YBP • YBP-NGO led by Providers • Convinced and empowered YBP to lead the service delivery guidelines development • Provided resources • Technical Assistance • Implementation • Printing and dissemination • Solicit opinion of all stakeholders • Solicit policy level support through strategic and frequent meetings with senior officials • Prepare a plan and obtain commitment and approval to participate in plan • Form a broad-based committee to steer process

8. Step 2: Ensure Broad Scope andCommitment • Expert Committee in • Indonesia’s National FP • Service Delivery Guidelines • Development • Representatives of: • Ministry of Health • Nat’l FP Coordinating Board • Service providers, clinical trainers, and their professional associations • Medical & Midwifery Faculty Representatives • Local NGOs, FP associations • Expert Committee in • Turkey’s National • Guidelines Development • Representatives of: • Ministry of Health • University • Service providers, trainers, and their professional associations • Local NGOs, FP associations • UNFPA and USAID cooperating agencies

9. Step 3: Develop Outline and Content • Indonesia Example • Identify the target audience • Providers at the PusKesMas • Need to Know Clear, Updated Information • Clinical • Program • Compact and affordable to be in the hands of all providers • Get input from all levels of the health service system pyramid • Identify practices that are positive • Conduct broad discourse on proposed guidelines • Utilize national and international resources

10. Step 3: Technical Resources Reference documents and resources guide the formulation of up-to-date guidelines: • WHO 2004 Eligibility Criteria • WHO 2004 Selected Practices Recommendations • Essentials of Contraceptive Technology, 2006? • JHPIEGO Infection Prevention reference manual, 2004 • CPI guidance documents

11. Step 4: Testing and Revising • Indonesia Example • Feedback from • Internal among editors and stakeholders • External among NGOs and Cooperating Agencies including UNFPA and WHO • Providers during Contraceptive Technology Update workshops • Iterative Review Process • Field testing done by a variety of providers • Review for technical accuracy, user-friendliness, internal consistency • Revisions should reflect client perspectives • Review and revise with sanctioning authorities

12. Step 5 Preparing For Dissemination • Host country plans strategy and ensures adequate funding • Formulate clear and flexible workplan • Plan to use a wide variety of formats • Go beyond distribution to ensure application in plan

13. Step 6: Dissemination Strategies for Success • Indonesia Example • Secure Documented Official Endorsements • Plan National Launch in a High Profile Event • Print Starter Copies for Distribution • Develop Target Distribution List • Encourage use of the material during training of providers • Encourage use in supervision tools • Involve and reach all organizations concerned • Plan series of workshops for different groups at different levels of service • Issue an official letter validating the guidelines and use other opportunities to broadcast them officially • Promote using creative mechanisms

14. Step 6: Dissemination and Promotion Strategies • Radio dramas • Dissemination workshops • Flyers • Internet • Hotlines • Audio cassettes • Posters and logos • Modeling by respected colleagues

15. Step 7: Hit All the Targets • Service delivery points • Training programs • Education programs • Program planning • Community linkages Source: Population Reports, Series J, Number 47, 1998.

16. Step 7:Kenya Service Delivery Example vs. • Pregnancy safely ruled out by checklist in 90% of women typically sent home • Of those pregnancies ruled out by checklist only <1/2% had a positive pregnancy by test Pregnancy Checklist DipstickÒPregnancy Test

17. Step 8: Ownership Encourages Adherence Use positive, team- based approaches that make providers partners in promoting guidelines use and solving problems in their application! Source: Population Reports, Series J, Number 47, 1998.

18. Step 8: Build Adherence Into The System • Indonesia Example • Dissemination activities led by team of National & Local Providers • Shared results of on- going survey on compliance issues during dissemination • Invited both providers and program managers • Identify focus of responsibility for adherence and authority for ensuring it • Ensure orientation and training around guidelines • Look beyond the guidelines for causes of lack of adherence

19. Ecuador Sustainability Study Step 8: Explore Reasons for Non-Adherence • Before: CEMOPLAF policy on IUDs required 4 revisits • Study: on impact of reducing mandatory IUD follow-up visits to 1 • Results: actual revisits reduced 36% while only detecting 7% less serious medical complications • Savings: $23,000 for clients, $10,000 for CEMOPLAF, 1800 provider hours annually

20. Step 8: Provide The Tools for Adherence • Send periodic content pieces reinforcing guidelines--especially problem-solving tips and solutions found by practicing colleagues • Develop/use job aids and coaching

21. Step 8 :Monitor Compliance • Methods to monitor compliance: • Self assessment (with checklist) • Supervision and training • Follow-up • Peer review • Medical monitoring • Record review • Client surveys • Action research Source: Population Reports, Series J, Number 47, 1998.

22. Step 9: Plan for Updates • Plan for periodic review early in process • Provide content and program updates to steering committee • Plan for host country self-reliance for guidelines revisions and updates • Establish mechanisms for providing technical professionals in the field with up-to-date scientific information

23. Step 10: Evaluate • Evaluate the integration of guidelines in daily service provision practices • Evaluate the impact on access to and quality of care, and accordingly take initiatives to strengthen these • Apply results of evaluation to new initiatives to strengthen quality and access • Integrate indicators into existing data collection systems

24. REFERENCE • STEPS IN GUIDELINES PROCESS, 1998 MAQ EXCHANGE POWERPOINT PRESENTATIONS • BP3K GUIDELINES DEVELOPMENT PRESENTATION, 2002