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P038 Completing the PDCA circle for guidelines within one organisation
  1. D Stemkens1,
  2. K Aben1,
  3. S Osanto2,
  4. J de Groot1,
  5. E Verhoof1
  1. 1IKNL, Comprehensive Cancer Centre The Netherlands, Utrecht, Netherlands
  2. 2Leiden University Medical Center, Leiden, Netherlands


Background Our organisation is closely involved in the continuous process of developing, implementing and evaluating (evidence based) guidelines for oncological and palliative care. we use the unique combination of data from our national cancer registry, our knowledge and experience as well as the knowledge and experience of medical professionals and patient representatives available through national and regional networks. As part of this process, each evidence based guideline is evaluated with the objective: 1. to get insight in the adherence; 2. to get insight in possible bottlenecks for the implementation in daily practice; 3. to stimulate further implementation by giving feedback.

Description of Best Practice The case of the guideline renal cell carcinoma will be presented. This includes the following steps: 1. selection of recommendations (based on the new guideline) by the guideline working group; 2. definition of indicators; 3. registration by trained registration staff of our national cancer registry; 4. analysis of the results; 5. presentation of results to professionals; 6. specific promotion of expertise and skills to further implement the guideline.

Lessons for Guideline Developers/Users The combination of development, implementation and evaluation of guidelines ’in one hand’ offers special opportunities for quality improvement. During guideline development it already becomes clear which recommendations will need extra attention during implementation. These recommendations are very interesting to evaluate, so that the feedback about these recommendations can help the professionals to further implement the guideline.

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