Implementation of evidence-based practices: Applying a goal commitment framework

The implementation of evidence-based practices translates research findings into practice to reduce inappropriate care. However, this process is slow and unpredictable. The lack of a coherent theoretical basis for understanding individual and organizational behavior limits our ability to formulate effective implementation strategies.

The study objectives are (a) to test the goal commitment framework that explains mechanisms impacting outcomes of major depressive disorder (MDD) screening guideline implementation and (b) to understand the effects of implementation outcomes on provider practice related to MDD screening.

Using data from the Determinants of Clinical Practice Guideline Implementation Effectiveness Study, the national sample included 2,438 clinicians from 139 Veteran Affairs acute care hospitals with primary care clinics. We used hierarchical generalized linear modeling to assess the following implementation outcomes: agreement with, adherence to, improvement in knowledge of guidelines, and delivery of best practices as a function of clinician input into implementation, teamwork, involvement in quality improvement activities, participative culture, interdepartmental coordination, frequency, and utility of performance feedback. We then estimated self-reported MDD screening practices as a function of these four implementation outcomes.

Results showed that having input into implementation, involvement in quality of care improvement, teamwork, and perceived value of performance feedback were positively associated with implementation outcomes. Provider self-assessed guideline adherence was positively associated with the likelihood of appropriate MDD screening.

Factors related to increased goal commitment positively predicted key implementation outcomes, which in turn enhanced care delivery. This study demonstrates that the goal commitment framework is useful in assisting managers to assess factors that facilitate implementation. In particular, participation, feedback, and team work equip organizational participants with better information about implementation targets, thereby increasing adherence. Instituting or improving systems or programs to facilitate timely, appropriate performance feedback and provider participation may help enhancing organizational change and learning.