Part 1. An overview on implementation of CPGs Part 2. CPGs & HTAs Presented during the 2nd Regional Workshop for CPG Adaptation, Tunis, Tunisia May 24-26 2016 A collaborative between INA Sante, WHO-EMRO, KSU

1. Overview on CPG
Implementation
(CPGI)
By
Dr. Yasser Sami A. Amer
MBBCh, MS Pedia., MS HCI, CPHQ, FISQUA
CPG Methodologist, CPG Steering Committee, CPG Unit, Quality
Management Department, King Saud University Medical City
CPG Adaptation Workshop, INA Santé, Tunisia, 24-26 May 2016

2. CPGI
“The concrete activities and interventions
undertaken to turn policies into desired
results“
Guidelines for clinical practice: from development to use. IOM, 1992
CPGs Practice
6/13/20162

3. CPG “Implementability”
Set of characteristics that PREDICT
the relative ease of implementation of
CPG recommendations.
Implementability…….BEFORE implementation
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4. How to Measure Implementability?
Ease and accuracy of translation of guideline
advice into systems that influence care.
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5. Dissemination & Implementation
Nothing could be more frustrating than
producing a CPG that is then ignored
by not being disseminated nor
implemented nor updated.
The concept of the ‘LIVING’ CPG
6/13/20165

6. :: Evidence to practice/ knowledge to action cycle ::
CPG Implementation (CPGI)
Strategies & Tools
6/13/20166

7. CPGI Tools

8. Adapt/ design CPGI Tools
to be made available at the point of care (* MR/ EMR)
Examples
• Clinical Algorithms
• Integrated Care/ Clinical Pathways
• Protocols
• Policies & Procedures
• Chart Documentation/ forms (e.g. Physician Order Sets:
paper vs. CPOE system +/- CDSS)
• Quick Reference Guides/ Physician Guides & Pocket
Guide/Reference Cards (at-a-glance summary of key
recommendations).
• Mobile Apps8 6/13/2016

9. • Clinical audit criteria (tool)
• Quality/ Performance measures (process, outcome KPIs)
• Quality Tools (e.g. FMEA)
• Slide Presentation.
• Wall Poster.
• Patient Resources/ Information (HE guides).
• Foreign language Translation (Non-Arabic, Non-French).
• Implementation Tool Kits (collections of tools and/or strategies).
• Staff Training/ Competency Material.
CPGI tools (cont’d)
6/13/20169

10. 6/13/201610
With or without Clinical Decision Support (CDS)

11. Mobile Apps (mHealth)
6/13/201611

12. NICE Guidance
‘Tools and resources’
• Baseline assessment
• Clinical audit
• E-learning module
• Slide set
• Tailored education
support
• Case scenario
• Commissioning guide
• Costing statement
• shared learning
• ‘Do not do’
recommendations
• Research
recommendations
• Guidance into
practice
6/13/201612

13. CPG implementation strategies/
interventions
6/13/201613

14. I - Professional interventions
• Identify barriers & facilitators to CPG implementation/ knowledge use
• Distribute and advertise (CPG educational material)
• Present CPG materials at meetings
• Local consensus process that CPG should be implemented
• Educational meetings (lectures, conferences, workshops, or CME/ CPD)
• Educational outreach visits
• Local opinion leaders (Clinical/ quality champions)
• Patient-mediated interventions
• Audit and feedback
• Reminders (manual or computerized)
• Marketing
• Others (?)
6/13/201614
Gagliardi A et al

15. II - Organizational interventions
(3 categories)
(i) HCP-oriented interventions:-
• Revision of professional roles or teams (aka. Professional substitution, boundary
encroachment)
• Leadership engagement
• Create a Clinical implementation/ multidisciplinary team
• Formal integration of services (aka. Seamless/ continuity of care)
• Skill mix changes
• Improve satisfaction of healthcare providers (non-financial)
• Communication and case discussion between distant healthcare providers
• Others(?)
6/13/201615

16. Organizational interventions
(cont’d)
(ii) Patient-oriented interventions:-
• Mail order pharmacies (e.g. compared to traditional pharmacies).
• Presence and functioning of adequate mechanisms for dealing with patients'
feedback, suggestions and complaints
• Consumer participation in governance of healthcare organization
• HE activities
• mass media campaign
• Others (?)
6/13/201616

17. Organizational interventions
(iii) Structural interventions:-
• Changes in the setting/site of service delivery
• Changes in physical structure, facilities and equipment
• Changes in MR systems (HIT)
• Changes in scope and nature of benefits and services (method of service delivery)
• Presence and organization of quality monitoring mechanisms/ Change in Quality
improvement or Performance Measurement systems
• Ownership, accreditation, and affiliation status of hospitals and other facilities
• Staff organization
• Others(?)
6/13/201617

18. CPG implementation strategies
Dissemination Process (print/ e-/website)
Local Clinical Champions.
Awareness raising/ training activities.
Networking and linking with existing projects
(e.g. CPD/CME activities, Accreditation, etc..).
Patients as champions for change.
Regular M & E (The ‘living’ CPG concept!).
6/13/201618

19. “Multi-faceted” are more
effective than single strategies in
CPGI!
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20. Facilitators and Barriers in CPGI
6/13/201620

21. Facilitators of CPGI
Domain
Positive attitude
Learning through small group interaction
Individual
Leadership support
Champions
Team work collaboration
Organizational
Scientific specialized association support
Inter-organizational collaboration
networks
Environmental
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22. CPG Implementation Failure!
BARRIERS!
Extrinsic to CPG:
provider & care system-related
Intrinsic to CPG: (>Methodology!)
ambiguity – inconsistency - incompleteness
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23. FMEA RESULTS – Major Failure Modes
Identified potential failure modes in CPGs implementation with the
highest RPN (≥ 80):-
1. Auditing of the CPGs (e.g. data management process).
2. Adaptation process (e.g. AGREE appraisal, Ext. review).
3. Networking with existing projects.
4. Awareness/training activities.
5. Accessible printed & electronic implementation tools
6. Advocates from clinical/ quality champions
23

24. RESULTS - Actions taken
1. Auditing: Supported by Pedia. CGC, DQT & QMD as a part of
Quality sustainability plan and CPG Program.
2. Adaptation: (e.g. AGREE: 4 appraisers, Review: all Stakeholders)
3. Networking: (e.g. Dept. QIP, CPD, Accreditation, Research)
4. Awareness/ training activities: Organized regularly.
5. Printed & electronic copies*: Available and accessible to HC
providers at points of care. *eSiHi!
6. Champions: Consultants/ senior practitioners encouraged to get
involved in CPG adaptation/ implementation.
24

25. 6/13/201625
CPG Implementation cycle

26. CPG Implementation cycle
6/13/201626
FinalCPGApproved+CPGITools
+Plan
FormulateImplementation
multidisciplinaryteam
Baseline(Pre-)Auditof
currentCP
PilotImplementation
Identifybarriers
Prioritizedissemination
strategiesandstart
Prioritize1–3keyRsto
implement
Prioritizeimplementation
strategies
Post-implementationM&E
Regularcheckpoints(PIPOH-KPI)
Regularreview&updateof
publishedevidence

27. Effectiveness of CPGs implementation
interventions
Slide courtesy of Dr. Ulfat Shaikh 6/13/201627

28. 6/13/201628

29. G-I-N Working Groups (IWG, PMWG)
6/13/201629

30. 6/13/201630

31. What is your role as a HCP in
CPGs? “spread the word”
1) CPG implementers/users:
“Your continuous feedback!”
2) CPG developers/adapters.
3) Improvement research projects.
6/13/201631

32. CPGI
• Start with prioritized with strong evidence
• Used a planned and structured approach
• Identify key stakeholders
• Understand facilitators and barriers
• Use evidence-based implementation interventions
• Monitor and evaluate effectiveness
• Modify and improve your approaches
•PLAN – DO – STUDY – ACT – ENJOY!
6/13/201632 Slide courtesy of Dr. Catherine Marshall

33. CPGs & HTAs
identifying similarities & differences
A collaborative discussion session
By
Dr. Yasser S. Amer on behalf of, King Saud University, CEBHC-KT, CPG
Program Expert Panel
CPG Adaptation Workshop, INA Sante, Tunisia
24-26 May 2016

34. Definitions
• Healthcare technology is defined as prevention and
rehabilitation, vaccines, pharmaceuticals and devices,
medical and surgical procedures, and the systems within
which health is protected and maintained.
• Technology assessment in health care is a
multidisciplinary field of policy analysis. It studies the
medical, social, ethical, and economic implications of
development, diffusion, and use of health technology.
Reference: International Network of Agencies for HTA (INAHTA) website
http://www.inahta.org/hta-tools-resources/
Note: A Memorandum of Understanding between INAHTA and G-I-N has been
signed at the INAHTA Annual Meeting in 2009.

35. HTA
“The systematic evaluation of properties, effects,
and/or impacts of health care technology. It may
address the direct, intended consequences of
technologies as well as their indirect, unintended
consequences. Its main purpose is to inform
technology-related policymaking in health care. HTA is
conducted by interdisciplinary groups using explicit
analytical frameworks drawing from a variety of
methods."
Goodman, Clifford S. HTA 101: Introduction to Health Technology Assessment, January 2004.
https://www.nlm.nih.gov/hsrinfo/evidence_based_practice.html

36. • CPGs & HTAs together, builds a body of best practice
initiatives. Evidence of the effectiveness of health
technology is only one part of the picture.
• Support evidence-based decision making by collecting
and analyzing [E] from research in a systematic and
reproducible way and make it accessible/ usable for
decision-making purposes
Both CPGs & HTAs . . . .

37. Why CPGs & HTA?
Similarities
•Same objectives – to inform policies and
practices
•Same EB approach and methodologies –
systematic reviews and economic evaluations
•Achieving more with limited resources
•Prioritized health topics can be shared

38. Links?
• Although, CPGs & HTAs are two standalone tools to support
evidence-based healthcare; Several links between them may
exist including:-
• Identification of high priority health topics for synthesis; topics that
have been already prioritized for CPGs’ development or adaptation
can be used to inform and prioritize topics for HTAs
• HTAs can further support an evidence-informed decision by policy-
makers whether to incorporate a new HT (e.g. pharmaceutical,
device,..etc.) in the HC system. A good example is chemotherapeutic
agents in LMICs.

39. CPGs versus HTAs: differences
HTAsCPGs
 Policy/ HC system level
(decision support)
 Clinical practice & patient level
(decision support)
 Judgements about the extent to
which these “recommended”
interventions should be
available in a specific HC system
are left to health policymakers.
 Recommendations from
EBCPGs, are considered the
most effective management of
a specific condition. They
mainly include benefits and
harms of the interventions.
Reference: European Observatory on Health Systems and Policies-HTA Policy Brief 2005

40. Conclusion
• HTA and CPG development share
objectives and methodologies
• Upstream HTA can inform downstream
CPG development
• CPGs can also inform HTA
Slide courtesy of MoH Singapore (G-I-N resources)

41. Questions for discussion
• From your experience, what are the most important factors
that facilitate CPGs implementation?
• What are the main barriers against successful and
sustainable CPGs implementation?
• Should HTA agencies (or projects) link up with CPG
agencies (or projects) ? Should these linkages be national
or international?
• Should HTA development/ adaptation be an integral part
of the CPGs development/ adaptation projects?
• Others………………………………..?

42. THANK YOU!
Dr. Yasser Sami Amer
yasser3amer@yahoo.com;
yassersami@alexmed.edu.eg;
yamer@ksu.edu.sa;
yassersamiamer@gmail.com