The health care services are continuously implementing new activities, terminating obsolete treatments, undergoing staff changes and organizational reconstructions. In spite of the relative high flexibility required in clinical life, the general “knowing-doing gap” also exists in the health services, including when it comes to patient-centered health promotion, i.e. clinical health promotion. Overall, it takes about a decade from establishment of solid evidence until it is implemented in daily life for the benefit of the individual patient and the society at large. This slow implementation has severe consequences and the unused potential for improvement is tremendous.

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Barriers for implementation

Numerous barriers have been identified for implementation, involving all levels from policy-makers and managements to the staff and patients. Some barriers are related to the policy-makers not basing policies and strategies on the evidence (1) and others originate from the tops of organizations – especially low management skills and support (2) Important barriers are described as related to the staff, including missing competences in clinical health promotion as well as own healthy or unhealthy lifestyle (3). Another challenge is the often non-existing basic teaching and training in implementation, pre- or postgraduate for the clinical, public health service and administrative staff who is going to do the implementation in real life.

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It may be a surprise for both staff, management and policy-makers that the patients often are positive to new interventions – especially when it comes to activities of health promotion, such asbeing offered smoking cessation intervention in relation to surgery (4-6). Actually, the patients could feel disappointed if not receiving this intervention (7).

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Closing the knowing-doing gap

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Easy-to-use Kit

In order to move from knowing to doing it is necessary to add an easy-to-use strategy. One of the newest is the step-by-step implementation kit described to support implementation of the WHO Surgical Check List all over the world (8). This list is to be used on the operation theatre as part of an improved patient safety effort, and it has already been implemented in many hospitals (Table 1).

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The kit describes a basic management process translated for individual use by the individual surgeon and others, who want to make evidence-based and interdisciplinary tools and guidelines work in real life. It includes a detailed description of each step (9). The process has three phases that start with the preparation, then enter the implementation, and finally nail the implementation with the maintenance phase. Altogether the three phases include a serial of steps. Some of the steps are easy to recognize, because they are well-known elements in the usual daily life.

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The line, box and the circle
Another kit to follow-up on the implementation process is actually used to follow the process of change. It is available for download free of charge. The three tools can be applied on oneself for reflection on personal barriers, ambivalence and decision-making, as well as for following the successes and challenges (10).

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WHO-HPH Standard recognition process
A new promising way to faster implementation of health promotion standards in hospital departments (11) seems to be described in the new model on the international multi-centre recognition project (12). This model includes a common workshop with teaching and training followed by baseline measurements and description of a quality plan with priorities based on the baseline results. After about 1 year of implementation a new status is collected to be followed up by a site visit, as included in the present issue of this journal. In general, more teaching and training in implementation on all levels is necessary to use the large potential for implementation for the benefit of the patients, the staff, organization and policy-makers.

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References
(1) Hawkes N. Government takes lessons from medicine to embed evidence into policies. BMJ 2013; 347:f6164
(2) Evans BA, Snooks H, Howson H, Davies M. How hard can it be to include research evidence and evaluation in local health policy implementation? Results from a mixed methods study. Implement Sci. 2013; 12:8-17
(3) Willaing I, Jørgensen T, Iversen L: How does individual smoking behaviour among hospital staff influence their knowledge og health consequences of Smoking? Scand J Public Health 2003; 31:149-55
(4) Pedersen B, Alva-Jørgensen P, Raffing R, Tønnesen H. Fractures and alcohol abuse - patient opinion of alcohol intervention. Open Orthop J 2011; 5:7-12
(5) Thomsen T, Esbensen BA, Samuelsen S, Tønnesen H, Møller AM. Brief preoperative smoking cessation counselling in relation to breast cancer surgery: a qualitative study. Eur J Oncol Nurs. 2009; 13:344-9.
(6) Villebro NM, Pedersen T, Møller AM, Tønnesen H. Long-term effects of a preoperative smoking cessation programme. Clin Respir J 2008; 2:175-82.
(7) Lindström D, Sundberg-Petersson I, Adami J, Tönnesen H. Disappointment and drop-out rate after being allocated to control group in a smoking cessation trial. Contemp Clin Trials 2010; 31:22-6
(8) WHO surgical safety checklist and implementation manual, 2008, (www.who.int/patientsafety/safesurgery/ss_checklist/en/) (Accessed 20.12.13)
(9) Canadian patient safety institute. Surgical Safety Checklist. (www.saferhealthcarenow.ca/EN/Interventions/SafeSurgery/Documents/How-to guide for the surgical checklist.pdf) (Accessed 20.12.13)
(10) Tønnesen H, (Ed.). Engage in the Process of Change; Facts and methods: WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals & Health Services, 2012
(11) Groene O. (Ed.). Implementing health promotion in hospitals: Manual and self-assessment forms. Copenhagen 2006. WHO Regional Office for Europe)
(12) Svane JK. Update on the WHO HPH Recognition Project. Clin Health Promot 2012; 2:123