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IMPLEMENTATION AND EVALUATION 79 implementation processes needs to be anticipated as guidelines are first disseminated, used, and evaluated. ⢠Sixth, implementation processes will not be static but will evolve as better methods are identified and less successful approaches are discarded. Such evolution may complicate evaluation. The rest of this chapter emphasizes practice guidelines and makes only occasional comments about medical review criteria, performance measures, and standards of quality. Implementation is discussed first, followed by a shorter section on evaluation. TYPES OF IMPLEMENTATION Implementation refers to the concrete activities and interventions undertaken to turn policy objectives into desired outcomes (Pressman and Wildavsky, 1973). In the context of this report, these activities are viewed as a set of partly coordinated, partly disjointed steps or activities that include formatting, disseminating, applying, and revising or updating guidelines. Two overlapping but distinct implementation tasks can be distinguished. One is implementing the public program established by OBRA 89. The other is implementing the practice guidelines themselves. Program Implementation OBRA 89 gives primary responsibility for establishing a program to develop and promote practice guidelines to the Department of Health and Human Services (DHHS) through AHCPR and its Forum. Necessary steps for implementing this program include hiring staff, developing a program agenda, establishing an advisory council, letting contracts, convening expert panels, and generally establishing and administering a broad, ongoing federal program.1 The IOM committee's advice about definitions and attributes of guidelines is intended to assist the agency with two aspects of program implementation: working with expert panels and assessing the results. Congress provided for an Advisory Council for Health Care Policy, Research, and Evaluation to advise the Secretary and the administrator of AHCPR on a broad array of activities. Council advice on the development of guidelines and the conduct of outcomes research must be handled by a special Subcouncil on Outcomes and Guidelines. Neither the Council 1 Private organizations, such as the American College of Physicians (ACP) and others that develop guidelines, face program implementation tasks that are similar in many respects to those faced by the Forum (ACP, 1986). The same statement applies to guidelines implementation.
