Facilitators of Clinical Guideline Implementation in Tertiary Care: A Systematic Literature Review

Clinical guidelines (CGs) can improve the quality of care in tertiary hospitals-but only if they are actually used. Past reviews listed facilitators, but did not explain why some work and others fail. This review fills that gap by asking: Under what conditions do facilitators succeed? We systematically reviewed 6948 records (PubMed, Scopus, Web of Science, Magiran, SID) through Nov 2025, selecting 45 high-quality studies. Using the MMAT tool and analytical thematic synthesis, we looked beyond what works to how and when it works. We found that three groups-policymakers, developers, and implementers-must work together in a cycle. Crucially, their actions only succeed under specific conditions: leadership helps only when it is visible, supported by resources, and accountable-not when it is top-down only, CGs are used more when they fit into daily workflow (e.g., emergency kits)-not just when they are simple or short, policies succeed only when paired with practical support (e.g., payment for guideline-based care, feedback systems). We also found that different health systems need different strategies: centralized systems need strong policy integration; high-autonomy settings need peer-led change; resource-limited settings need simple, adaptable tools. Successful implementation is not about more facilitators-but about better-aligned ones. We recommend a shift from top-down orders to collaborative, context-aware planning, where frontline staff, managers, and policymakers co-design solutions.