Kosovo was the pilot site for the GREAT Network’s in-country guideline prioritization and implementation planning work. In October 2012, local stakeholders including clinicians, healthcare providers, healthcare administrators, researchers/academics, and policymakers from Kosovo gathered as participants of a two-day workshop that involved focus group discussions followed by a prioritization meeting. Of the World Health Organization’s (WHO) maternal and perinatal guidelines, the guideline identified in consultation with local stakeholders and in-country experts to be a priority in Kosovo was decided to be the WHO guideline on the prevention and treatment of postpartum haemorrhage.
During the workshop, participants discussed the local priorities, barriers, and facilitators to implementing the WHO guidelines in diverse clinical settings across Kosovo. Prior to the in-person workshop, key informants were identified and asked to participate in online surveys and telephone interviews to share their perspectives on guideline priorities and implementation considerations in the Kosovo context. Themes of importance, feasibility, and impact were used to guide the workshop prioritization activities and the development of the resultant nine recommendations for optimizing guideline implementation in Kosovo.
Prior to the in-person workshop, an online survey was administered and telephone interviews were conducted with key stakeholders to inform a preliminary understanding of key priorities related to the identified WHO maternal health guideline. The findings of pre-workshop activities were used to inform workshop facilitators about stakeholder perceptions and to guide the proceedings of a two-day in-person workshop.
During the in-person workshop, focus group discussions were conducted with participants on Day 1. Participants were assigned to one of two focus groups; 11 participants attended focus group #1; and 8 participants attended focus group #2. During the prioritization exercise on Day 2, facilitators and participants reviewed and discussed results from pre-workshop activities and focus groups using a nominal group process (Jones & Hunter, 1995). Participants were asked to discuss and rate the importance WHO guidelines and previously identified barriers to WHO guideline implementation using a process consistent with the RAND appropriateness method (Fitch et al., 2001).
Key findings from pre-workshop and workshop activities were organized into 3 main categories:
1. Barriers to implementation
At the level of health care providers:
- Lack of understanding of the methodology used by WHO to identify guideline needs and develop resulting guidelines.
- Lack of agreement amongst health care professionals regarding which recommendations to adhere to and which guidelines to implement.
- Recommendations were being created without formal engagement of, and input from clinicians.
- Lack of communication amongst clinician groups, specifically obstetricians and midwives.
- Lack of documentation and monitoring systems in place to evaluate current practices or improvement initiatives, making knowledge of impact impossible unattainable.
- Lack of training and continuing education opportunities available for clinicians and students.
At the health care system level:
- Lack of communication between levels and sectors of government.
- Lack of Ministry support.
- Lack of clarity regarding roles and responsibilities.
- Lack of public data and documentation.
- Lack of resources.
2. Facilitators to implementation
Participants suggested that in order to facilitate implementation it would be beneficial to introduce motivational strategies for clinicians and managers. For example, participants suggested incorporating both incentives and regulations (with monitoring and enforcement measures) into clinical practice to encourage staff to adhere to WHO guidelines.
3. Recommendations for implementation
Recommendations to address some of the above-mentioned barriers to implementation were identified by participants. These included:
- Create a centralized system for data collection across clinical settings as well as for formal and informal channels for practice sharing.
- Incorporate standards into clinical practice including a monitoring system for guideline adherence.
- Create motivational strategies such as, incentives for health care staff, (including managers and clinicians) to encourage guideline adherence.
- Increase communication across stakeholder groups including clinicians, managers and policy makers through participation in activities such as guideline development committees.
- Create a guideline implementation working group with representative stakeholders at the local level.
- Develop a small working group with local representatives from clinician groups, the Ministry of Health guidelines committee and quality portfolio, clinical or health services researchers, and the WHO to move forward with implementation.
- Consider offering workshops on guideline development methods (including use of GRADE (Guyatt et al, 2008), on appraisal of guidelines using AGREE, and on guideline adaptation for representatives from the Ministry of Health and clinical groups.
- Consider engaging some of the local clinicians on the WHO guidelines development group.
- Engage those interested in guideline development and implementation from neighbouring countries in the workshop activities and create a ‘virtual’ community of practice to share experiences and avoid duplication of effort.
If you are interested in learning more about the pre-workshop and workshop activities conducted in Kosovo, please read our final report.
Implementation of the WHO maternal and perinatal guidelines in Kosovo requires consideration of unique barriers as identified by local stakeholders. The impact of recent conflict including, a fragmented health care system and disjointed infrastructure for communication among health care stakeholders were identified as prominent barriers to guideline implementation. However, the workshop activities offered a timely and valuable opportunity to rebuild capacity at the level of individual health care providers and the health care system in preparation for development and execution of a successful implementation plan. In addition to improved local capacity and interprofessional communication, there are also important opportunities to share knowledge and implementation resources internationally.
Since the initial in-person workshop in October 2012, follow-up activities in partnership with Kosovo have been conducted and are currently active. A high-level overview of these follow-up activities include:
- A workshop was hosted in Kosovo in December 2013 that focused on frameworks and methods used to appraise, adapt, and implement clinical practice guidelines.
- A process evaluation is currently being conducted. As part of this evaluation, follow-up focus group discussions and interviews are planned with workshop participants in Kosovo in November 2014 to document and assess progress made on implementation activities and recommendations since the in-person workshop in October 2012.