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Implementation Guide Introduction and Information

What do we mean by implementation?

“Implementation in this second sense involves the programs and activities that take guidelines out of the rather abstract phase of development and into the actual world of health care decision making and action.” 1

For the purposes of awards for self-reporting your implementation project the term “implementation” can be understood to mean; use of a guideline in part or full in the course of clinical practice, health care contracting, policy making, educational programs, or other health care related activities; and/or use of guidelines to fulfill the elements of an initiative, regulation, or requirements.

Guidelines for Clinical Practice: From Development to Use

Aims of Implementation Initiative

In 2022 the Bree Collaborative began an implementation and evaluation initiative. The aim of the Bree Collaborative Guidelines is to address high variation in the way that care is delivered, that are frequently used but do not lead to better care or patient health, or that have patient safety issues. The goals of this implementation are to provide resources, mechanisms for collaboration in order to  increase holistic, person-centered care, to improve equity in care and health outcomes, to improve the use and transparency of health data, and to provide a mechanism for controlling costs through the uptake of the Bree Guidelines. To encourage more broad spread adoption of guidelines and best practices, the Bree Collaborative has developed this implementation guide, along with a self-report system tied to awards and a state-wide dashboard.

1. Institute of Medicine (US) Committee on Clinical Practice Guidelines; Field MJ, Lohr KN, editors. Guidelines for Clinical Practice: From Development to Use. Washington (DC): National Academies Press (US); 1992. 3, Implementing Guidelines: Overview and Illustrative Cases. Available from:

Project exploration to evaluation

The Bree Collaborative IG is divided into a root menu which can be accessed using the drop-down menu under the “IMPLEMENTATION” tab in the tool bar at the top of the page. Topics are grouped into sections by general topics:

  • Common Measures
  • General Guidelines
  • Aging
  • Behavioral Health
  • Chronic Disease Management
  • Infectious Disease Management
  • Managing Pain
  • Oncology
  • Reproductive Health
  • Surgery
  • New Guidelines in Development

Sections are further divided into specific report topics and each topic includes the following sub-sections:

  • Guideline information, including year published, scope, language, date for review, last date of evidence search, methods and a general description
  • Read online, link to the full report
  • Implementation Checklists, by audience
  • Resources and Tools
  • Metrics and Operational Measures
  • Examples of Implementation

The IG is designed to encompasses all stages of implementation, from exploration of a topic to evaluation of a completed project. Case studies and topic specific resources support initial steps for organizations to better understand the scope and requirements an implementation project will need such as planning, staff, time, funding, etc.  Each of our reports includes recommendations for specific audiences, such as payor, health care organizations or practitioners, which have been translated into specific checklists for tasks.

Together with subject matter experts, the Bree has also developed operational measures to help implementers gauge progress of the project and demonstrate the achievement of milestones.

The Evaluation Survey Question Bank is available both as a stand-alone resource and to help organizations craft evaluations that have both internal and external validity by aligning evaluation questions with other organization’s efforts. The Bree collects both questions and evaluation data in order to support question validation and reliability. More information on how to use the Question Bank is available on the Question Bank home page.

Making progress on implementation

This guide has been designed to make sure that your team can answer the who, what, when, how, and why of an implementation project for each of our reports before moving into the execution phase. We have employed a strategy of implementation levels in this IG in order to provide interested parties with manageable, step-wise actions to adapt guidelines into their unique context. These levels help support the five stages of implementation, which are: 1) exploration, 2) installation, 3) initial implementation, 4) full implementation, and 5) expansion and scale-up. Below is a summary of the Bree Collaborative Implementation levels.

Level 1:

Level 1 identifies activities, processes, and competencies for each guideline topic that address a minimum standard of care. Generally speaking, these are activities, processes, and competencies that medical groups or practitioners can accomplish internally. These activities may be centered around things such as training, system upgrades or basic in-house programs or processes (exploration, installation, initial implementation).

Level 2:

Level 2 processes and activities address a standard of care for each guideline topic that reflects increased integration and coordination with external partners. These activities may include things such as team-based care, tracking patients, or using population health managements (full implementation).

Level 3:

Level 3 encompasses activities, processes, and competencies for each guideline topic which include full coordinated care, exemplary patient-centered approaches, and measurement of change in patient outcomes. These activities may include things such as coordination with multiple partners or spreading practices throughout your organization (expansion and scale-up).

Implementation Framework

Bree Collaborative Transformation Plan is being modeled on the Knowledge to Action (KTA) framework. This means that we conceptualize the translation of the guidelines we have created as a cyclical process that includes feedback from those who are doing the work of implementation. To that end, we have designed a self-report system and case study format to provide some tools for organizations, clinicians, health plans, and other stakeholders to provide us with information on the usefulness of the checklists, tools, metrics, and other resources we have provided and on the gaps in knowledge that still exists.

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Theory of change

The Bree Collaborative Primary Care Transformation implementation is designed on the assumption that individual organizations working together create systemic change. Some of our efforts involve priming the system for change by creating common metrics, providing information to regulators and legislators, and aligning our work to address the needs and gaps in the health care system through the creation of bundled payment models and guidelines to address health topics where no guidelines exist or where there is variation among providers or organizations. In this way we hope to help create an environment where multiple stakeholders can most easily act on guidelines that support systemic change.

These assumptions are in line with Prosci’s ADKAR Change Management Model. The ADKAR model consists of 5 stages:

  • Awareness of the need to change
  • Desire to support change
  • Knowledge of how to change
  • Ability to demonstrate skills and behavior
  • Reinforcement to make the change stick

To support the first two items on this list, the Bree Provides webinars, learning collaboratives, and conferences to raise awareness about guidelines and to inspire the desire in health system stakeholders and organizations to change. This implementation guide is designed to provide knowledge on the “how” of change, while our self-report system was created to allow stakeholders to demonstrate skills and behaviors. Finally, our awards program is meant to act as reinforcement to help make change stick.

The Bree Collaborative has developed a roadmap to health system transformation. This document helps stakeholder and other interested parties conceptualize how our work contributes to system wide changes in health care quality and cost for people in Washington State.

Bree Health Ecosystem Roadmap

This is a place holder to embed a version of the excel sheet Emily has made for where guidelines are applicable (inpatient, outpatient, hospital, etc.)

The Bree Collaborative self report system is designed to encourage providers, delivery sites, hospital systems and health plans to demonstrate their progress on guidelines implementation and their commitment to quality care. Location of organization, guideline topic, and level of implementation that is captured from the self-report submission will be aggregated and displayed in our dashboard. 

Why report:

Self-reporting allows us to provide many services and different types of recognition. Reporting helps us craft individual support through a better understanding of an organizations environment and context. Data that is self reported is de-identified, aggregated and displayed on our dashboard to allow organizations to compare their progress to others, find partners doing similar work, or to help patients find organizations that are providing quality care.

The Foundation for Health Care Quality also uses the self-report data for awards and recognition. Please see the Awards section below for a full description. The Bree Collaborative may also reach out to submitting organizations if they indicate that they are interested in developing a case study as a way to spread recognition of quality work.

How to report:

Use the form below to document your progress on the implementation of the Bree Collaborative Guidelines. The self-report form uses a simple measurement system for individual actions of implementation and provides your organization with an overall score:

  • 0 -No action taken;
  • 1 -Actively considering adoption;
  • 2 -Some/similar adoption;
  • 3 -Full adoption

The overall scores are to help us understand barriers to implementation and gaps in use. They will be used to help identify area where organizations may need additional support or resources.

The format is an excel workbook which contains sheets for each guideline. To complete reporting, choose the relevant report topic (for example, LGBTQ care, Colorectal Cancer Screening, etc.) and fill out the 1-12 items for each instance of implementation your organization. Each instance can mean by department, by delivery site or for the entire organization if you are using the reports to inform care throughout your organization.

You can access the form by downloading the Excel document from the link below. Once it is filled out you can attach it, along with other supporting documents in the submission form on this tab. If you ave questions, please contact or

(Trail Blazer Award Submission Form)

    To submit the Trail Blazer award, once you have downloaded and filled out the Trail Blazer Submission Form and have collected your supporting documentation, you can upload the files below to submit them to the Bree Collaborative.

    To submit for the Mountain Climbers award, once you have been informed of eligibility and received a link, download and fill out the Mountain Climbers Submission form and upload the files below.

    If you have any questions, please contact or

    Rational and description

    The aim of these awards is to highlight and celebrate quality work being done by many different organizations.

    Being Considered for Awards

    Any organization can be considered for an award.

    Types of awards

    The Path Finder awards are based on the submission of the Bree Collaborative checklists and supporting documentation. There are three levels of awards for completion of the checklists for each level of implementation – Path Finder Level 1, Level 2, and Level 3. The checklists and documentation can be submitted using the self-report form in the section above. (What do they get?)

    The Trail Blazer award is given in recognition for having implemented guidelines or having processes that have fidelity with Bree reports. Fidelity is determined by filling out the “score card” in the self-report section above. Anyone submitting self-report data to the Bree Collaborative who receives an overall implementation score of 2.75 (?) or greater for a specific report will automatically receive an award. We inform each submitter by email, which includes information on how to apply for our Mountain Climber Award. (Awards could include buttons for staff, wall certificates for departments, or flags for organizations, depending on the spread of their work. Example: if they have only done it in one unit or floor, they get buttons or a certificate, if they have done it organization wide, they get a flag or banner for their entrance.

    The Mountain Climber award is given for exemplary implementation efforts that focus on the Bree pillars of transformation, i.e. equity, data exchange and transparency, person-centered care, cost/financing or ROI. Any organization receiving a Trail Blazer award is automatically eligible for consideration. The next step is to fill out the Trail Blazer Awards form to provide further information about how your work forwards the Bree’s pillars of transformation of equity, patient-centered care, ROI (health outcomes, cost, etc.), and data exchange.

    This award is given out  (once or twice a year?). A panel of judges is convened to score all the submissions on the criteria of generalizability, innovation, overcoming barriers, breadth of implementation work, (or other qualitative concepts we think will help celebrate them and that would be useful to share with others). (Awardees receive a plaque, be invited to speak on our webinar, have a celebration planned for them, pictures on website)

    Award Criteria

    Pathfinder awards

    • Submission of proof of completion of level 1, 2 or 3 checklist

    Trail Blazer awards

    • Submission of self-report form, supporting documentation, and average score of 2.75 for fidelity with Bree Guidelines.

    Mountain climber awards

    • Recipient of Trail Blazer award.
    • Submission of Mountain Climber award form.
    Dictionary of Terms
    • Audience: audiences are actors such as individuals, organizations, or state agencies.
    • Implementation: the execution or practice of a plan, a method or any design, idea, model, specification, standard or policy for doing something.
    • Holistic care: the provision of care to patients that are based on a mutual understanding of their physical, psychological, emotional, and spiritual dimensions.
    • Person-centered care: Integrated health care services delivered in a setting and manner that is responsive to the individual and their goals, values and preferences, in a system that empowers patients and providers to make effective care plans together. (CMS)