The document discusses the adaptation and implementation of clinical practice guidelines (CPGs) at hospitals of two universities in the Middle East and North Africa region. It provides an overview of the CPG adaptation and implementation program launched at Alexandria University Hospitals in Egypt and King Saud University in Saudi Arabia. It describes how over a dozen CPGs have been adapted through various theses projects at Alexandria University Hospitals, and outlines the current status of the CPG program established at King Saud University Medical City, which has adapted over 30 CPGs across various clinical departments.

1. ‫الر‬‫ـن‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫م‬‫الرح‬‫هللا‬ ‫ـم‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫س‬‫ب‬‫ـيم‬‫ـ‬‫ـ‬‫ـ‬‫ـ‬‫ح‬
In the name of Allah. Most Gracious, Most Merciful

2. Evidence-Based Clinical Practice
Guidelines (CPGs)
Adaptation & Implementation in
Hospitals of Two Universities in
MENA
6/7/2014 2
Presented By
Dr. Yasser Sami Amer, MBBCh, MS
MS Pediatrics, MS Healthcare Informatics
Hospital CPGs Advisor, EBRU, QMD KSUMC
General Coordinator, Hospital-Wide CPG Committee
Member, G-I-N Adaptation WG steering grou
From Alexandria University Hospitals in Egypt
to King Saud University in Saudi Arabia

4. 1999
2006
2004

5. First Postgraduate Master thesis in [Clinical Practice Guidelines
Adaptation & Implementation]
in Alexandria University Faculty of Medicine, Egypt
6/7/2014
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KSUMC: KAUH 2014
5

7. Alexandria University Hospitals
Healthcare Quality Directorate
Center for Evidence-Based Clinical Practice
Guidelines
(AUH – HCQD, CEBCPGs)
(Founded Nov. 2008)
http://www.med.alexu.edu.eg/cebcpgs/
Member of Guidelines International Network (G-I-N)
(Since May 2009)

10. Founding Members 2008
• Prof. Dr. Mahmoud Elzalabany
• Prof. Dr. Tarek Omar
• Prof. Dr. Nabil Dowidar
• Prof. Dr. Afaf Ibrahim
• Dr. Yasser S. Amer
• Dr. Hossam Ashour
• Eng. Ahmed Mourady

11. First Workshop in Egypt: Adaptation of CPGs
2009 (AFM-GIN-ADAPTE)

12. *12 M.Sc. Theses plus 1 Ph.D. thesis to produce 13 Adapted EBCPGs
4 Finalized Adapted CPGs by CEBCPGs, HCQD-AUHs through MSc Theses (till
3/2012) in PEDIATRICS DEPT.:
1- Treatment of Acute Childhood Asthma in ER - AUCH: Dr. Yasser Sami Amer (Finalized,
Approved , Disseminated & Implemented).
2- Treatment of Positioning & Attachment Breast Feeding Problems in BFCC - AUCH: Dr.
Georgina Ramsis (Finalized & Approved).
3- Triage and Acuity Scale in A & E Dept., AMUH: Dr. Mary Christeen Nabiel Sharobeem
(Finalized, Approved & Disseminated ) – the only thesis outside the Pediatrics Dept.
4- Treatment of HIE in Neonates in NICU: Dr. Walid Gamal AbdelKhaliq
(Finalized & Approved).
5- Treatment of ADHD in children in AUCH: Dr. Mariana Iskander Amin (Finalized & Approved).
6-Management of Acute Bacterial Meningitis in AUCH: Dr Mariam Adly (Finalized & Approved).
9 Adapted CPGs in progress by Pediatrics Dept. & CEBCPGs, HCQD-AUHs through
MSc/PhD Theses (till 8/2012):
1. Diagnosis of acute attack of seizures in AUCH: Dr. Soheir Farouk AbdelSalam
(Finalization Phase).
2. Treatment of acute attack of seizures in AUCH : Dr. Islam Yousry A.Moneium (Set Up
Phase).
3. Management of Epilepsy in children in AUCH: Dr. Shimaa Anwar (Set Up Phase)
4. Treatment of Childhood Autism in AUCH: Dr. Farioz Ibrahim (Finalization Phase).
5. Treatment of Chronic Asthma in AUCH: Dr. Reem Galal Ghazal (Finalization Phase).
6. Treatment of Community Acquired Pneumonia in AUCH: Dr. Zobaida Eltazmany
(Finalization Phase).
7. Treatment of Allergic Rhinitis in AUCH: Dr. Shahinaz (Set Up Phase).

13. WHO Patient Safety Friendly Hospital Initiative in
the Eastern Mediterranean Region
Alexandria University Children’s Hospital
6/7/2014
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14. G-I-N 2009 Lisbon
G-I-N 2012 Berlin

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“The Adapted ADAPTE Process for CPGs Adaptation”

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3 New Tools3 Modified Tools
For the Guideline Adaptation: A Resource Toolkit Version 2.0

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http://qualitysafety.bmj.com/content/22/Suppl_1/43.1.abstract?sid=302fcfca-c444-
4bd3-a295-c75c811b7d49 (last cited 7/6/2014 in BMJ Quality & Safety)

32. Evidence-Based Clinical
Practice Guidelines (CPGs)
Adaptation &
Implementation Program
Launching CPGs Implementation
in King Saud University Medical City
(KSUMC)
6/7/2014 32
Presented By
Dr. Yasser Sami Amer, MBBCh, MS
MS Pediatrics, MS Healthcare Informatics
Hospital CPGs Advisor, EBRU, QMD KSUMC
General Coordinator, Hospital-Wide CPG Committee
Member, G-I-N Adaptation WG steering grou

33. KSUMC CPG PROGRAM
current status 2013 – 2014
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34. Clinical Practice Guidelines (CPGs) Program
of King Saud University Hospitals/ Medical City
KSUHs Taskforce Responsible Staff from:
Clinical Practice Guidelines Committee;
Quality Management Department;
Clinical Departments (CPGs subcommittees);
Shaikh Abdullah Bahamdan Research Chair for Evidence-
Based Health Care and Knowledge Translation;
Top Management & Leadership of College of Medicine
and University Hospitals (Future KSU Medical City)
09 JAN 2014 Antibiotic Prophylaxis in Surgery 34

35. CPG Program Relations (integration)

36. HOSPITAL-WIDE CLINICAL PRACTICE GUIDELINES
COMMITTEE (July 2009)
QT
EBHC-KT
QM
D
KSUMC CPGs
Program

37. Guidelines International Network (G-I-N)
www.g-i-n.net
EBHC-KT Chair, King Saud University
Org. Member since 2009
(1st Member from Gulf & 3rd Member from MENA Countries)
Founded in Nov. 2002

39. KSUMC CPGs in Numbers
 Hospital-Wide CPG Committee Members: 27
 Departments participating in CPG Program: 21
 Health topics identified for CPG projects: 53
 CPG adaptation projects finalized: 33
 CPGs finalized & approved by CPG Committee: 19
 CPGs finalized & implemented: 17
 CPGs uploaded to QM website & relevant desktop in points of
care: 17
 CPGs implemented & audited (data collected): 8
 CPGs implemented & audited (data analyzed): 3

40. Who is the contact person for EBCPGs
in your department?
 Head, Department CPG Subcommittee
 Members, Department CPG Subcommittee
 Department Quality Focus teams (former
Accreditation teams)
 Hospital CPG Advisor and CPG Committee General
Coordinator
 Medical Secretary, Hospital CPG Committee
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41. Pediatrics
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+1 CPG reviewed

42. Critical Care (ICU)
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+1 CPG reviewed

43. Medicine
6/7/2014
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44. Psychiatry
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45. Pharmacy
(Drug Info Center)
6/7/2014
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+16 CPG reviewed

46. Ophthalmology
6/7/2014
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47. Orthopedics
6/7/2014
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+1 CPG reviewed

48. Otorhinolaryngology (ENT)
6/7/2014
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49. Obstetrics & Gynecology
6/7/2014
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+2 CPG reviewed

50. Surgery
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+1 CPG reviewed

51. Nursing
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+3 CPG reviewed

52. PCC (Family Medicine)
6/7/2014
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+6 CPG reviewed

53. Anesthesiology
6/7/2014
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+1 CPG reviewed

54. Emergency Medicine
6/7/2014
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+10 CPG reviewed

55. Dermatology
6/7/2014
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58. Examples of KSUMC Clinical Practice
Guideline Adaptation
& Implementation Projects
presented and/or published in
International Conferences AND
National Events

59. The adapted CPG for Management of Diabetic
Ketoacidosis in children from the Department
of Pediatrics
• Presented by Dr. Sara Mohamed, Associate Professor &
Consultant of Pediatric Endocrinology & Metabolism and
Head of Pediatrics CPGs Subcommittee presented in two
international conferences:-
1. American Endocrine Society Conference, San
Francisco, USA. CPG: challenges and
opportunities in 14/6/2013 ENDO 2013 15-18/6.
2. European society of pediatric endocrinology
conference, Milan, Italy in 20/9/2013 – DKA
Guidelines: Saudi Experience.

60. Featured Poster Presentation Number: FP32-6 Poster Board Number: MON-282
https://endo.confex.com/endo/2013endo/webprogram/Paper6468.html
A
DISCLOSURES: Nothing to disclose
Development and implementation of Clinical Practice Guidelines
in Pediatric Endocrinology: Challenges and opportunities
Sarar Mohamed, Hala Omer, Nasir Al Jurryaan, Amir Babiker, Hessah Al-Otibi, Rana Hasanato, Shaikh Iqbal
,Mohamed Elfaki Osman, Nouf Alkhemis, Ali Abdo, Abdulrahman Al-Nemri
Department of Pediatrics & Chemistry, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

62. The adapted CPG for Management of Bipolar
Disorder from the Department of Psychiatry
•Presented by Dr. Yasser Amer, AND
Professor Lubna Al-Ansary
presented in 10th International
Guidelines International Network
(G-I-N) Conference in San Francisco,
USA in 18-21 August 2013 and
presented the KSUMC CPG Program
activities in the G-I-N Adaptation
Working Group Meeting in SF, USA

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G-I-N 2013 San Francisco

64. The Adapted CPG FOR Central Vascular Access Device
(CVAD) FROM THE NURSING DEPARTMENT
6/7/2014
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64
 Featured in the E-VAN May
2014 issue (Electronic
Newsletter of AVA) by Ms
Maan Ciocson.
 Publication in JAVA (in
progress) by the CPG
Adaptation working group.

65. National Representation
• 15-16/5/2013: Active participation in ‘Developing Strategic
Vision for Saudi Center for Evidence-Based Health
Care, Ministry Of Health workshop, Riyadh, KSA
•KSU College of Medicine & University Hospitals Representatives
were Professor Lubna Al-Ansary, Dr. Ayman Abdo, Dr. Yasser S. Amer
and Ms. Nada Alkhamis )

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PART I

68. Evidence-Based
Clinical Practice
Guidelines
Concepts & Definitions

69. Two Different Approaches to
Evidence-Based Practice
Clinical Practice Guidelines (CPGs)
•“Top-down” approach
• Tell clinicians how to practice
• Favored by health care systems
Evidence-Based Medicine (EBM)
•“Bottom-up” approach
• Teach clinicians how to find answers
• Favored by medical educators

70. EBP definition
The integration of best
research evidence with
clinical expertise and patient
values
Sackett et al 2000

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72. Evidence-to-practice process
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Knowledge Translation
Implementation research
System/ Provider and Quality
Improvement

74. Clinical
Care GAP
Best
Practice
Clinical Care
Gap
Knowledge
Translation
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76. What is “EBM” NOT?
• What we have always done !;
(not old hat or just the same old medical practice; as evidenced in wide
practice variation)
• “Cookbook Medicine”!
EBM specifically advocates for individualized application of evidence to patient
care, not forcing patient care to conform to generalized evidence
• Only a cost-cutting trick !;
it is intended to guide practitioners to provide the best, not necessarily the cheapest,
care.
• Only RCTs !;
(Also with best relevant evidence applicable to the situation in
question)
– EBM is tracking down the best external evidence from
scientific research to answer our clinical question(s)…

77. Definition: (old)
“Systematically developed statements to assist
practitioner and patient decisions about
appropriate health care for specific clinical
circumstances” (IOM 1990).
Increasing international interest in the
development and implementation of CPGs.
Clinical Practice Guidelines (CPGs)
77

78. CPGs New Definition
CPGs are “Statements that include
Recommendations intended to optimize
patient care that are informed by a
Systematic Review of evidence and an
assessment of the benefits and harms of
alternative care options”.
Committee on Standards for Developing Trustworthy CPGs
(IOM-AHRQ 2011)

80. Rationale for CPGs
• Worldwide concerns about:
▫ Unexplained variations in clinical
practice
▫ Rising health care costs
▫ Exponential growth of information
• Aim of Clinical Practice Guidelines:
▫ To facilitate more consistent, effective and efficient
practice and improve health outcomes for patients

82. • Physicians
• Nurses
• Pharmacists
• Decision makers
• Patients
• Public
19th March 2013 EBCPGs: Dr. Yasser Sami Amer 82

84. Read
Adopt
Adapt
Develop
CPGs ?

85. Different Options to deal with CPG

86. Process/ Methods

87. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 87

88. Adaptation of CPGs
Is the systematic approach to the endorsement
and/or modification of a guideline(s) produced
in one cultural and organizational setting for
application in a different context. Adaptation
may be used as an alternative to de novo
guideline development, e.g., for customizing
(an) existing guideline(s) to suit the local
context.
http://www.adapte.org/
http://www.g-i-n.net/

89. 6/7/2014 89

90. Hospital-Wide Policy & Procedure for
Hospital CPGs Adaptation
SEPT 2013

91. Team - Topic
Total Number of
Health Topics for
CPGs from all
departments
53
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92. Selecting a CPG Topic
 Prevalence of the condition (high volume)
 Patient safety concern (high risk)
 Under-, over-, misuse of intervention(s)
 Burden due to the condition
 Practice variation
 Costs of different practice options
 Likelihood of effectiveness of CPG
 Potential for improving quality of care and/or
outcomes
 Existence of relevant good quality CPGs

93. 21 KSUMC CPGs Subcommittees
1. Department of Pediatrics
2. Department of Critical Care
3. Department of Psychiatry
4. Primary Care/ Family Medicine Clinics
(Ambulatory Care Services)
5. Department of Pharmacy
6. Department of Emergency Medicine
7. Department of Medicine
8. Department of Orthopedic Surgery
9. Department of Otorhinolaryngology
10. Department of Ophthalmology
11. Department of Cardiac Sciences/ KFCC
(Cardiology – Cardiac Surgery)
12. Department of Surgery
13. Department of Obstetrics & Gynecology
14. Department of Dermatology
15. Department of Anesthesiology
16. Department of Laboratory Medicine &
Pathology
17. Department of Nursing
18. Department of Radiology
19. Health Education Center
20. Department of Rehabilitation Medicine
21. Department of Infection Control
93
New (in progress)
1. Department of Occupational Health & Safety
2. Department of Clinical Nutrition

94. Health/ Clinical/ Key Questions
Patient (& disease characteristics)
Intervention(s)
Professionals (Target users)
Outcomes (purpose of the CPGs)
Healthcare settings (& context)
19th March 2013 EBCPGs: Dr. Yasser Sami Amer 94
CPG Scope: PIPOH Model

95. Health Question Tool (modif.)
6/7/2014
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100. Inclusion / Exclusion CPGs Selection Criteria (6)
1. Methods of Development: Evidence-Based CPGs:
(Detailed Methodology not Consensus-based CPGs
(Expert opinion)
2. Author(s): Organization and Specialized Society not
single authors.
3. Country: International not national CPGs.
4. Date of Publication: range of year of publications:
last 5 years or less (e.g. 2010 – 2014) – except if none!
5. Language: English CPGs only
6. Status: only Original source CPG (de novo
developed) rather than adapted CPGs

101. CPG selection criteria Tool (new)
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101

103. Producers Finders

104. • Specialized societies
• National agencies
NICE
SIGN

105. Organization Name
Country
URL
Produc
er
Finde
r
FREE PAID
Guidelines International Network
(G-I-N)
Int’l http://www.g-i-n.net F √ √
World Health Organization (WHO) Int’l http://www.who.int/topics P √
National Institute for Health
& Clinical Excellence (NICE)
UK
http://www.nice.org.uk/page.aspx?o
=ourguidance
P √ √
Scottish Intercollegiate Guidelines
Network (SIGN)
Scotland
http://www.sign.ac.uk/guidelines/in
dex.html
P √
New Zealand Guideline Group (NZGG) NZ http://www.nzgg.org.nz P √
Registered Nurses Association of
Ontario (RNAO)
Canada http://www.rnao.org P √
National Guidelines Clearinghouse
(NGC)
USA http://www.guidelines.gov F √
US National Library of Medicine,
National Institutes of Health
(PubMed)
USA
http://www.ncbi.nlm.nih.gov/pubme
d
OR http://www.pubmed.gov
F
√
(Abst
racts)
√
(Fu
ll
Tex
t)
Institute for Clinical Systems
Improvement (ICSI)
USA http://www.icsi.org/knowledge/ P √

106. AAP CPGs
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107. ACP CPGs
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108. NKF CPGs
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109. CPG Producers:
National Agencies
NICE
National Institute for
Health & Clinical
Excellence
www.nice.org.uk

110. SIGN
Scottish
Intercollegiate
Guidelines Network
www.sign.ac.uk
CPG Producers:
National Agencies

111. RNAO Toolkit
• Toolkit for
implementation
of CPGs
• www.rnao.ca

112. AHRQ
National Guideline
Clearinghouse
www.guidelines.gov

113. Shaikh Bahamdan’s Research Chair for Evidence-
Based Health Care & Knowledge Translation
Member of G-I-N since Oct. 2009
Free access to International CPG Library of G-I-N

114. http://c.ksu.edu.sa/ebhc/en

116. http://ebhc.ksu.edu.sa/gin/index.html

119. PubMed
US National Library of
Medicine
National Institutes of
Health (NIH)

120. EVIDENCE PYRAMID ?
120

121. 19th March 2013 EBCPGs: Dr. Yasser Sami Amer 121

122. Evidence Pyramid
SR
RCT
Cohort
Case control
Case series
Case report
Expert opinion
I
II
III
IV
A
B
C
LevelsofEvidence
GradesofRecommendations

123. Level
Evidence
Grade
Recomm.
Strength
EVIDENCE PYRAMID

124. CPG-ICU-002 (VTE) 2013
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125. HWCPG-ENT-001 (ABRS) 2013
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126. HWCPG-PHARM-001 (Vanco)
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127. How to assess of the quality of any CPG ?
19th March 2013 EBCPGs: Dr. Yasser Sami Amer 127

128. Assess guideline
quality
ADAPTE TOOL 9 AGREE II
Instrument
23 items in 6 domains
7 point response scale
Domain scores
Recommendations
19th March 2013 EBCPGs: Dr. Yasser Sami Amer 128

129. AGREE II 6 Domains
DOMAINS
1 Scope & Purpose
2 Stakeholder Involvement
3 Rigour of Development
(Methods)
4 Clarity & Presentation
5 Applicability
6 Editorial Independence

130. 6/7/2014 130
The concept of the
‘LIVING’ CPG

131. End of Finalization Phase
1. CPG Subcommittee submit finalized CPG draft to
Evidence Base & Research Unit, Quality
Management Department for review;
2. Submit to Hospital-wide CPG Committee for review
of adaptation process methodology and final
approval;
3. Congratulations letter to Chairman of department
4. Start dissemination and implementation in
relevant departments;
5. Follow up, clinical auditing & measurement in
relevant departments;
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132. Dissemination &
Implementation
Nothing could be more
frustrating than producing
a CPG that is then ignored
by not being disseminated
nor implemented
19th March 2013 EBCPGs: Dr. Yasser Sami Amer 132

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PART II

135. CPGs
Implementation Strategies
& Tools
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136. CPG Implementation
• “The concrete activities and
interventions undertaken to turn
policies into desired results“
Guidelines for clinical practice: from development to use. IOM, 1992
CPGs Practice

137. CPG Implementation Failure….WHY?
Extrinsic to CPG:
provider-specific & care
system-related
Intrinsic to CPG:
ambiguity – inconsistency
- incompleteness

138. Facilitators: Questions
From your experience, what are
the most important factors that
facilitate CPGs
implementation?

139. Individual
 Positive attitude
 Learning through small
group interaction
Organizational
 Leadership support
 Champions
 Team work collaboration
Environmental
 Professional association
support
 Inter-organizational
collaboration networks
Facilitators

140. Implementability
• Set of characteristics that PREDICT
the relative ease of implementation
of CPG recommendations.
Implementability…….BEFORE
implementation

141. How to Measure Implementability?
Ease and accuracy of
translation of guideline
advice into systems
that influence care.
GLIA TOOL
Richard N. Shiffman, MD, MCIS
Yale Center for Medical
Informatics, Yale University
2005 - 2011

142. SIGN is customizing implementation support
to every CPG. Ali El-Ghorr et al
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143. CPG implementation strategies
Dissemination Process (print/ e-/website)
Local Clinical Champions.
Awareness raising/ training activities.
Networking and linking with existing
projects (e.g. Dept. Clinical Rounds, CPD/CME
activities, Accreditation, etc..).
Patients as champions for change.
Regular M & E (The ‘living’ CPG concept!).
Saturday, June 7, 2014
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144. Dissemination process
(1st TOOLS!!!)
• I- PRINTED MATERIAL (booklets, brochures, cards, CPG
binders in some nursing stations, etc..)
• II- ELECTRONIC MATERIAL:
(a) Full CPG copies (PDF files) on desktop of PCs in the following
points of care:
• outpatient clinics (ambulatory)
• nursing stations in the inpatient wards
• nursing stations in the DEM
• Pharmacy
(b) The QM website (KSU email log in)
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145. Local Clinical Champions
Clinical quality champions must be
known within the organization &
community as both promoting and
delivering best practices (EBP) with
their patients.
Strategic leadership. The Healthcare Quality Handbook.
JB. 26th Ed. 2011/2012
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146. CPG
Implementation Tools
:: Evidence to practice/ knowledge to action cycle

147. Adapt/ design CPG implementation tools
available at the point of care (* MR)
TYPES
1. Clinical Algorithm.
2. Integrated Care/ Clinical Pathways*.
3. Protocol.
4. Chart Documentation/ checklists/ forms (e.g. Physician Order Sets* later
CPOE/eSIHI).
5. Quick Reference Guides/ Physician Guides & Pocket Guide/Reference Cards
(at-a-glance summary of key recommendations 5 or 1-2 pages).
6. Clinical audit criteria (tool)
7. Quality (outcome/performance) measures
8. Slide Presentation.
9. Wall Poster.
10.Patient Resources/ Information (health education guides).
11.Foreign language Translation (Non-English, Non-Arabic).
12.Implementation Tool Kits (collections of tools and/or strategies).
13.Staff Training/ Competency Material.
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148. Clinical algorithm
• A diagram of the guideline
recommendations presented as a step-
by-step decision-tree
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150. Clinical Pathways
Syns.: Integrated Care Pathways, Multidisciplinary
pathways of care, Pathways of Care, Care Maps,
Collaborative Care Pathways.
• Definition: structured, multidisciplinary care
plans designed to support …………………(3)
1. implementation of CPGs and protocols.
2. clinical management, clinical and non-clinical resource
management, clinical audit & financial management.
3. detailed guidance for each stage in the management of a
patient with a specific condition over a given time period,
including progress and outcomes.
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151. Care pathways differ from CPGs,
protocols and algorithms as they are
utilized by a multidisciplinary team
and have a focus on the quality and
care co-ordination.
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152. Pathways’ Four main Components:
1. Timeline.
2. Categories of care or activities and
their interventions.
3. Intermediate and long term outcome
criteria.
4. Variance record (to allow deviations to
be documented and analyzed).
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153. Benefits
1. Support the introduction of EBM and use of
CPGs.
2. Support clinical effectiveness, risk management
and clinical audit.
3. Improve multidisciplinary communication,
teamwork and care planning.
4. Can support continuity and co-ordination of care
across different clinical disciplines and sectors.
5. Provide well-defined standards for care.
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154. Benefits (cont’d)
6. Help reduce variations in patient care (by
promoting standardization).
7. Help improve clinical outcomes.
8. Help improve and even reduce patient
documentation.
9. Support training.
10. Optimize the management of resources.
11. Does not override clinical judgment.
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156. Differences between
Clinical Algorithm Clinical Care Pathway
 Decision – making.  Coordinating Care.
 Series of questions that guide
designing sequence of steps.
 Goal statement that guide key
elements of care, roles and sequence
of activities
 Generic; applicable to all patients  Individualized; may be designed for
individual patient (integrated care
plan)
 Not time-related  Time-related; hours in ED, days in
acute care, weeks in chronic and
home care.
 Staff not mentioned clearly  Usually multi-disciplinary staff and
should be mentioned in the care plan
 Systematic actions  Systematic actions
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157. Differences between
Clinical Algorithm Clinical Care Pathway
 Not outcome-related (does not
include standards or outcome of
care)
 Outcome-related (includes standards
or outcome of care)
 Only clinical processes  Clinical & non-clinical processes
 Maps  Maps
 Does not include order or priorities  Includes order and priorities
 Includes continuous feedback
through tracking and analysing
variance
 Includes continuous feedback
through tracking and analysing
variance
 No details of treatment  Includes details of treatment
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158. Standard Order Sets/ Standing
Orders
Collection of medical orders in a pre-filled
ordering paper template forms or in a
computerized physician/provider order entry
system (CPOE) for a selected group of patients
throughout the different disciplines and it is
usually based on EBCPGs to standardize diagnosis
and treatment.
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159. Two types are currently identified in KSUMC:-
1) Expert/ Consensus-based order sets: these
forms are result of the collaboration of one or more
clinical departments and would require careful review
and clinical expertise.
2) Evidence-Based order sets (Systematic
Methodology): these forms are based on hospital
adapted CPGs that were officially approved by the
hospital CPGs committee (refer to HWQPP – 010)
Computerized Provider Order Entry (e-SIHI)
IN PROGRESS!
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160. HWQPP – Standing orders development,
revision & deletion (2014)
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161. Computerized
Physician Order Entry
(CPOE)
And Medication Errors!
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162. Current Hospital Info. System
(2 icons)
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163. Current Hospital IS (2 icons) (cont’d)
1. KKUH – Lab Access System
2. Centricity Web –PACS
Not comprehensive HIS or EMR!
Not supporting CPOE!
 Physicians order Ix in “paper forms” and Lab &
Radio staff encode results.
 Physicians order Rx in “paper” physician orders.
Unclear illegible hand-writing of doctors.
Paper request forms sometimes get lost or
damaged.
Patient safety implications.
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With or without Clinical Decision Support (CDS)

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167. SOLUTION
• New HIS (e-SIHI) project supports CPOE.
• Physician Build team assigned to build CPOEs
in collaboration with Lab., Pharm & Nursing.
• CPOEs (order sets) based on hospital
approved adapted Evidence-based CPGs.
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169. Expected benefits of HIS w. CPOE
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170. Expected benefits of HIS with CPOE
1. Reduce Medication Errors (patient safety)
2. Serve as a reminder for busy clinicians (education)
3. Clinical decision support during data entry
(Evidence-Based CPGs)
4. Reduce time (save seconds/ mouse clicks): more
time spent with patients??
5. Improve tracking & record keeping
6. Improve communication & integration of patient
information.
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171. Protocol
• What is the difference between a "clinical guideline," "practice
parameter," and "standard"?
• The phrases "protocol," "practice parameter," "pathway,"
"standard," "consensus statement," etc., are used in many
different contexts and may not necessarily be a clinical practice
guideline.
• Clinical protocols are more specific than CPGs,
defined in greater detail; provide a comprehensive
set of rigid criteria outlining the management
steps for a single clinical condition or aspect of
organization"
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172. Audit Criteria/ indicators & Quality Measures
• Systematically developed statements that
can be used to assess the
appropriateness of specific healthcare
decisions, services, structure,
performance, and outcomes
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173. Some Examples of currently monitored
indicators for year 2013-14
• Structure Indicators (2)
• Clinical documentation
• Performance Indicators (4)
• Length of stay
• Outcome indicators (18)
• Medication error
• Adverse drug reaction
• Mortality rate
• Morbidity rate
•Other clinical audit criteria have been identified
special to some CPGs topics
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174. Patient information
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175. Launching CPG pilot implementation
 Timeframe: ……… Months
 Starting date: …./ …../ ………
 Monitoring & Evaluation Checkpoint #1:
• TEAM (Taskforce) Essentially everyone is a
• “CPG Champion”
 Physicians
 Nurses
 Pharmacists
 Technicians
 Allied HC professionals
 Others
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176. Identify & Prioritize
Key recommendations & outcomes
• # 1 …………………………………………………………………………………………………………….
• # 2 ……………………………………………………………………………………………………………..
• # 3 ……………………………………………………………………………………………………………….
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Identify Implementation Barriers
I. Who? Key stakeholder analysis
[each…….Influence × Support: HIGH/LOW]
II. Other barriers? (e.g. equipment,
medications, workflows,….etc.)

177. Action plan
• Timeframe: (e.g. 3 Mo., 6 Mo., 1 Yr.)
• Identify targets:
• Primary: e.g. patients/clients
• Secondary: e.g. Doctors, Nurses,…..etc.
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Strategies Short term plan Long term plan
FEB
10/2
MAR APR
15/4
MAY JUN JUL AU
G
SEP OC
T
NOV DE
C
• Prepare/ finalize imp. Tools (paper & E-)
FinalSurvey2ndCycleofAC
• Awareness campaign
Top management/ Dept. Chair + clinical champions
IT ( screens/desktops)
• Education campaign (target users, clients
and carers)
• Dissemination (Formats: paper/ E-)
• Other Implementation initiatives
• System of care (change needed)
• Evaluation: M & E (Clinical Audit)
• Sustainability

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PART III

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180. 2nd Accreditation Canada Cycle 2014
Together We did it  !

181. Thank YOU all for listening
181
Contact Information: Dr. Yasser Sami Amer
Emails: yasser3amer@yahoo.com; yamer@ksu.edu.sa
Mobile: +966-50-857-7246, +966-51-525-2439
Office: +966-11-46-91341