OBJECTIVES: To identify the strategies used and degree of implementation of Clinical Practice Guidelines (CPG), during 2022, in accredited Health Institutions in Colombia

METHODS: Descriptive observational study. Convenience sampling. Hospitals with ICONTEC accreditation were included. Hospitals not certified as "University Hospitals" were excluded. Collection of information during 2022: a) Contact by e-mail. B) Virtual meeting. C) Submission of a form in Microsoft Forms. The variables were analyzed with relative and absolute frequencies for qualitative variables. Summary and dispersion measures were presented for quantitative variables

RESULTS: The survey was answered by 9 hospital institutions (out of 16 hospitals accredited and certified as University hospitals).

The mean number of CPGs per institution was 215 (SD 103). 66.66% (6/9) have used the AGREE REX or ETd tools of GRADE. 77.77% (7/9) use focus groups to identify barriers and facilitators. All use more than one method (audits, continuing medical education, computer developments, trainings) for their implementation process. Of the 7 institutions with a compliance schedule, the mean compliance rate was 78% (SD 16%). Dissemination means such as applications and focus groups with clinical staff have been catalogued as successful implementation strategies, while mass mailings by e-mail or intranet are catalogued as less successful. 55.55% (5/9) have used clinical or administrative outcome indicators reflected in the care process. The mean adherence to the 5 main CPGs was 86.66% (SD 0.41%). Three institutions (33.33%) measure adherence processes more than 4 times a year. In 55.55% (5/9) of the institutions, the CPGs have enabled the incorporation of new technologies in their institution

CONCLUSIONS: Putting CPG recommendations into practice in institutions involves designing, planning, executing dissemination and follow-up strategies in organizations. All the evaluated institutions have clinical evidence implementation processes, being the use of computer applications and focus groups the more frequent techniques.