Purpose:  In order to promote decision-making based on available evidence, we developed Facilitated Process Improvement (FPI) as a pragmatic approach to implement new guidelines for advanced chronic kidney disease (CKD). The approach is based on the Theory of Constraints (TOC), and is intended to be a general technique for developing effective practice improvement strategies for busy clinicians.

Methods: FPI is distinct from other forms of process improvement because it moves the formative work of guideline implementation from the practice to a national team consisting of a professional organization and practice improvement methodologists. FPI is based on the three TOC questions about change: what to change (understanding current processes, undesirable effects and their root causes), what to change to (establishing functional specifications), and how to cause the change (developing tools to address the root causes).  The table illustrates the steps of FPI and the participants in this CKD practice improvement effort.

FPI Steps	Participants/Data sources
1. Establish functional specifications: what the care processes intend to accomplish	CKD guideline
2. Investigate processes of care in variety of site-types to understand the process, reasons why processes fail to meet functional specifications	Focus groups: nephrologists, non-nephrologists, patients
3. Develop a practical tool to attack root causes of process failures	Literature search Nephrologist interviews Focus groups: nephrologists, non-nephrologists, patients National expert working group (WG)
4. Develop a meta-tool to guide local tool selection	WG

Results: The result is the “Advanced CKD Management Toolkit” consisting of implementation tools (e.g. a flow-sheet, a referral form to ease communication between providers) and the meta-tool, which is in two forms. The “quick start” form is based on typical practice vignettes (e.g. “a busy primary provider with no interest in managing advanced CKD patients”). The “insight” form guides providers through an exercise to understand local processes and the potential for specific tools. The application of the meta-tool will be the only function of the site involved in guideline implementation.

Conclusions: FPI provides an explicit link between evidence and practice that takes advantage of the conceptual framework of TOC, and builds on principles of total quality management (TQM), but reduces TQM’s substantial demands. In effect, FPI transmits what is known about process improvement to local personnel committed to guideline implementation but limited by resources and experience.