What are clinical guidelines and who are they designed for The purpose of clinical guidelines is help clinicians and patients make appropriate decision about health care They are intended to be used by clinicians ( physicians, nurses and other health professionals) Clinical guidelines are developed by expert panels consensus and through rigorous clinical meta-analysis Much of the focus on clinical guidelines began in early 1990s At the time the Agency for Health Care Policy and Research,,,,, now the Agency for Healthcare Research and Quality was the only agency with the availability to merge outcomes research with clinical guidelines Today the Cochrane Collaboration is the premier data warehouse for clinical guideline publication and oversight.
The key importance of clinical guidelines is in their ability to In fact Clinical guidelines are considered by many as a tool that can bridge the gap between what is practiced and what science supports. Despite their enduring existence, clinical guidelines in many cases have rarely been adopted or accepted into clinical practice. WHY
Mostly their concern that applying clinical guidelines will promulgate cookbook medicine That guidelines will not be reliable nor relevant to the individual clinical characteristics of patients And finally liabilities form either imposing (bad guidelines) or liability from not However, with a continually expanding base of clinical research in the areas of evidence based medicine (meta-analysis) these concerns are beginning to lesson, and clinical guidelines are becoming more accepted
In today's rapidly changing healthcare environment there is increasing emphasis on Like pay for performance that focus on these aspects of care……. The same considerations that more than a decade ago promoted the use of clinical guidelines……….. For this reason , now more than ever before, implementing clinical guidelines in working towards collaborative participation poses widespread applicability.
The main objective of this research was to identify the most effective strategies for implementing clinical guidelines Administrators familiarized with these strategies have a better potential to develop standards within their organizations that facilities improvements in cost, efficiency, and outcomes.
To complete this,, this study utilized a method of systematic review Endorsed by the Cochrane Collaboration EFFECTIVE PRACTICE AND ORGANIZATION OF CARE Systematic reviews are recognized as appropriate for the review of interventions designed to improve the health professionals practice. A systematic review for this research was appropriate because
Because this study was not of a clinical focus, and did not attempt to quantify vast amounts of clinical research into evidence based synthesis. According to the Centers for Reviews and Dissemination, it is not appropriate to use meta-analysis when ….. The construct of this research followed The guidance on the conduct of narrative synthesis in systematic reviews ……… cited elsewhere the guidance workgroup comprised of international panel of experts in qualitative research to devise guidance approved by the Cochrane Collaboration for systematic review research for the use of non-meta-analysis (quantitative) studies.
In this research process as is the case for many systematic reviews, steps one and two were conducted prior to concluding the need for a systematic review. Mapping is process that identifies the relevancy of literature available on a particular topic of interest to refine the need for a systematic review. This process occurred during the initial literature review. The second step was completed prior to the formal research proposal acceptance with a refined question that asks: What are the most effective strategies for implementing clinical guidelines.
For study inclusion, the methods used follow the standards in systematic review inclusion criteria using Population Intervention Comparison and Outcomes. In this research studies were assigned by the following inclusion criteria
For grading data extraction, the Evidence for Policy and Practice Information EPPI centre approach was applied to evaluate study Robustness for
Applying the methods for inclusion criteria and robustness, a literature search was carried out using the Dayton Memorial Library access to the EBSCO-HOST database including Academic search premier, Business source Premier, CINAHL, And Medline for all publications limited to full text years 1990-2007. Search included full texts published 1990-2007 and included the following search terms
An excel spread sheet was used to track and manage the data extraction for all articles included after initial exclusion of 2598 articles
This table shows the organization of the data for identification and extraction
Synthesis combined two methods thematic analysis grouping and reciprocal translation
This slide shows an example for the organization of thematic analysis grouping “ synthesis groping” This grouping revealed a listing of common themes, metaphors and concepts that I was then able to deduce into primary themes for synthesis using reciprocal translation
From this process, ten themes were identified the first were considered to non-effective and were identified to being to barriers for effective implementation
Conceptual findings were included in the discussion of this research. The observation from this study that differs from others is the relationships involved with successful implementation and in particular the characteristics of organizational culture successful in adopting clinical guidelines. To build this hypothesis I used the works of Levy et al. to assimilate comparisons to theory social influence.
To conclude this research it was desirable to project a set of evidence-based protocols for successful implementation Future research needs to support more outcomes based studies for guielines implementation to validate or not their effectiveness in clincial practice, and a similar study on the barriers to guidelines implementation would compliment this study by providing an evidence based comparison. The limitations of this study include a publication bias, for accessing only full text articles availbel through the selected database serach, research fatigue and minimized reseracher bias. Therfore I cam up wilth a listing of protocols supported by the evidence of this synthesis and have provided that listing on the back sheet of your handaouts.
Effective strategies for
Effective Strategies forImplementing Clinical Guidelines;a systematic reviewA presentation of graduate researchfor the students, faculty and guests ofRegis University December 01, 2007
“Clinical practice guidelinesare systematically developedstatements to assist practitionerand patient decisions aboutappropriate health care forspecific clinical circumstances”(Institute of Medicine,1990)
ImportanceReduce variation in clinical practicesImprove quality outcomesImprove cost effectiveness
Criticisms‘Cookbook Medicine’Not ReliableNot relevant to the presenting condition(s)Liability
A changing environment• Increased emphasis on clinical quality• Patient safety• Cost effectiveness• Transparency• Payment structures (pay-for-performance)
Research ObjectiveIdentify the most effective strategies ofimplementing clinical guidelines throughan evidence based approachValidate physician trustGuide health policyPresent opportunities to promote cost effectiveimprovements in patient care
MethodsEndorsed by the Cochrane Effective Practice andOrganization of Care (EPOC)• Systematic review methodology has the ability tomanage potentially unmanageable amounts ofinformation (Torgeson, 2003)
Using qualitative research insystematic reviewsWhen is not appropriate to use meta-analysis?• Broad review question• Diverse studies (mixing apples with oranges)Guidance on the Conduct of NarrativeSynthesis in Systematic Reviews;qualitative research methods from the Institute for health research atLancaster University, London.
Steps for Conducting NarrativeSynthesis• Mapping• Specify the Review Question• Identify studies for inclusion• Data Extraction and quality appraisal• Synthesis• Reporting conclusions
Inclusion Criteria using PICO1) Study meets 4 PICO2) Study meets 3 PICO3) Study meets 2 PICO4) Study meets 1 PICO5) Study meets 0 PICOIdentify studies for inclusion
Data extraction and qualityappraisalEPPI centre approach Trustworthiness Appropriateness Relevance Overall WeightA) HIGHB) MEDIUMC) LOW
Search Strategy• Database search; EBSCOhost• Full-texts published 1990-2007• (clinical guidelines OR clinical practiceguidelines OR evidence based guidelines)and (implement OR disseminate ORintegrate) and/or (quality improvement ORprocess improvement)
Yield• First search yielded 2727 abstracts forreview• Second screening evaluated 129 articles• Appraisal identified 56 articles for criticalreview by first and second revieweragreement• Final appraisal identified 33 articles forsynthesis
a r t ic le p d f #Population(setting)Intervention(Implementationfactors present)Comaprisons(pre/post design)Outcomes(identifiedsupported)ATrustworthinessBAppropriatenessCRelevanceDOverall weight comments1211980.pdfHospitals yes yes yes 1 b high medium medium medium research does not provide c2444820.pdfclinicical alliance yes no yes 2 b medium medium medium medium clinical focus, lacks approp3009671.pdfPeds Clinics yes yes yes 1 b high mdium high medium controled study, lacks stron3740011.pdfclinicians yes no yes 2 c medium low medium low qualitative desing of guidlein3970231.pdfGP yes yes Yes 1 a high high high high controlled study with strong3970284.pdfPCP/GP yes yes yes 2 b medium medium low medium qualitative aevaluation of us3972072.pdfHospitals Hungry yes yes yes 1 a high medium high high trustworthy study methods,4460579.pdfSingle practice yes yes yes 1 a medium high high high not scholorly, strong approp4997435.pdfNursing no no yes 3 c medium low low low research based opinion5172083.pdfno no no no 5 c low low low low commercial proposoal5184270.pdfGP Austraila no yes no 3 c medium low low low lacks appropriateness to an5184435.pdfPractice no no no 4 c low low low low lacks appropriateness to an5186676.pdfFP Canada yes yes yes 1 b high medium medium medium qualitative evaluation with co5277923.pdfUrban GP yes yes yes 1 b high medium medium medium qaulitative desing, lacks app5302024.pdfHospital yes yes yes 1 b high medium low medium trustworthy research, lacks5333208.pdfhospital units yes no yes 2 c medium low medium low lacks approrpiateness to an5383238.pdfpractices yes yes yes 1 a high high high high trustoworthy research desig53832385520966.pdfAlliances yes no yes 2 c low low medium low consensus, lacks appropria5608247.pdfclinics yes yes yes 1 a high medium high high qualitaive research design,5661963.pdfno no no no 5 c low low low low has no appropriateness to a5801733.pdfclinics Finland yes yes yes 1 b medium medium low medium qualitative desing lacking in5861964.pdfhospital units yes yes yes 1 b medium medium medium medium qaulitative research desing,5928424.pdfSNF 10 yes yes yes 1 a high high high high experimental design, strong6071232.pdfhospital yes no yes 2 c low low medium low non research, lacks approrp6433398.pdfHealth Trusts yes yes yes 1 b medium medium high medium trustworthy research design6494343.pdfCommunity RN yes yes yes 1 b medium high high high action research with approp6697833.pdfno no no no 5 c low low low low no relevance or appropriaten6712275.pdfBirth Center yes no yes 2 b medium medium medium medium moderate appropriatness to6725285.pdfnone yes no yes 3 c low low medium low opinion based, moderate re6756415.pdfno no no no 5 b low medium high medium opinion based, with a strong6756432.pdfhospital China yes yes yes 1 a high high high hgih trustworthy research desing6756432.pdf6822903.pdfhospital yes yes yes 1 b low medium high medium lacks research design, has6823752.pdfhospital yes no yes 2 b medium medium emdium medium lacks research design, has6879242.pdfperinatal unit yes no yes 2 b medium medium low medium lacks research design, mod6879246.pdfneonate unit yes no yes 2 b medium medium low medium lacks research design6906180.pdfHMO clinics yes no yes 2 a high high medium high trustworthy qualitative desig6910687.pdfhospital yes yes yes 1 a high high high high mixed method reserch, app6985898.pdfhospitals 4 yes yes yes 1 c high low low low controled study, lacks appr6987359.pdfhospital yes yes yes 1 a high medium high high controlled study, has appro7254449.pdforganizationgroup hospitals yes no yes 2 a high high high high trusworthy study desing, st7296678.pdfhospital yes no yes 2 a high medium high high trustworthy study design, h7296678.pdf
Synthesis• Thematic Analysis GroupingGrouping by common metaphors, concepts and themesdifferentiated by effective vs. non-effective strategy• Reciprocal TranslationExplores relationships within and between studiesMeta-ethnography approach to derive a constantcomparison of themes to deduce primary conclusions
ReferenceCommon themes,concepts, metaphors.Effective implementationCommon themes,concepts, metaphors. NotEffective implementation Population Methodunit ofmeasureHetlivek et al. 1999 1-a-1computer decision support, no physicianor organizational impetus, no use ofsupplementary materials forimplementation measures discrepancywith guidelinesphysicianclinicquantitativeexperimentalcomparativediscrepancyCoquard at al. 2002. 1-a-10Physician consensus, organizedprocess, Physician (opinion leaders)led, existing computerized guidance,comparative measure hospitalexperimentalcase controlcomparativetx complianceBrown et al. 2004. 1-a-13organized process, existing computerEMR, reminders, prompts, chartposts, auto personalized referralletter,hospital andphysiciancliniccase studyevaluationcomparativeicd auditWright & Maydom,2004 1-a-16existing computer system, prompts,reminder, auto print guide,case studyprgmevaluationcomparative txicd-9Clarke et al. 2005 1-a-17independent CADS built into existinghospitals system, required additionalnurse and physician processing, printout guides for diseaseregionalhospitalscase studyprgmevaluation use of systemRudisill et al. 2006 1-a-24med order existing computer orderentry, pocket cards, requiredphysician training, pharmacists led,gatekeeper (organizational impetus) hospitalcase studyprogramevaluationcomparativeorder to cpgFeldstein et al. 2006 2-a-6existing computer EMR, personalizedemail to physician links toestablished pt EMR, system query,sends reminders and follow-up onestablished intervalsHMOorganizationexperimentalcase controlcontrol group,interventiongroupcomparativeicd-9, txPasztelyi & Schuler,2000 1-a-24printed guideline and establishedprotocols, mailed with current physiciancomparison feed-back, Intent was tomotivate physician behavior with use ofpeer comparison, no training, nosupplemental guidance, no physician ororganizational impetus.physiciangroupsqualitativepostdisseminationsurvey comparativeMarshall et al. 2001 1-a-4Benchmark, organizational impetus,Team champion facilitator, clinicalappraisal feed-back, peer comparisonfeed-back, process organized,physician accountability, flexibility forindividualized center use.physicianclinicscase controlwith surveyfollow-upcomparisonwith cpgbenchmarkLee et al. 2002. 1-a-7forced organizational led, senior staffresponsibility, educational lecture nodissemination. No supportive tools orsupplemental guides. hospitalsingle casestudyadherence toto guidelinesMiller et al. 1999 1-a-8organized process, phased, QIimpetus, change agent( championled) regular audit and feedback, smallsession training, supplemental guides( laminated cards, fact sheets,pamphlets, standing orders, careplan, pathways) hospitalcase studyprogramevaluationcomparativeaudit
Results non-effective• Implementation strategy was passive• Guidelines are not generally accepted• Guidelines are to long or complex• Implementation lacks accountability andownerships• Implementation process was unorganized orrequired competing organizational values
Results Effective• Implementation is effective when applied tostructured quality improvements• Implementation is effective when guidelines areare used as a benchmark or other comparativemeasure• Regular feedback is critical to successfulimplementation• Assistive supports in real-time help facilitateimplementation• Organizational setting must be supportive
Conceptual findings• Quality Improvement facilitates social influencingbehavior by acting as its vehicle• Feedback and use of other comparative measurespromotes group and individual competition & facilitatingsocial influence through perceived intention.• Knowledge translation; The use of assistive supports inreal time that promote guidelines implementationpresents a social influence at the level of interpersonalcognitive processing• Organizational cultures are a construct to social influencewhere the organizations social structure has the mostability to influence either positively or negatively to thedesired implementation.
AcknowledgementsSpecial thanks to Cassidy Smith from the ColoradoClinical Guidelines CollaborativeJennie Popay and the teams for the providing themethods group Guidance on the conduct ofNarrative SynthesisMy friends family and colleagues for their patientsand support in helping me make this happen