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Implementing Implementing GuidelinesGuidelines
E-GAPPS WorkshopE-GAPPS Workshop
Sue Pingleton, University of Kansas
Dave Davis, AAMC and University of Toronto
Agenda• Welcome and introductions• The clinical care gap:
» A macro perspective (Dave)» A local Perspective (Sue)» Why does the gap exist? Group Discussion
• Using educational tools to close the gap» The KU experience (Sue)» An evidence-based toolkit (Dave)
• Interactive Session: closing the gap in your settings» Small group work» Report back
• Wrap-up
Tell us about yourself• Guideline developer • Methodologist • healthcare provider• Health administrator • Journalist• Government policy maker • Private policy maker • Consumer/patient advocate
• Professional society member
• Educator• HIT Specialist• Information
Specialist/Librarian•
• How long in the guideline business?
• Background– MD– PhD– RN– Other health professional– Administrator– Policy expert– other
Current practiceCurrent practice
Ideal, evidence-based Ideal, evidence-based practicepractice
clinical care gapclinical care gap
The clinical care gap
clinical care gapclinical care gap
Examples of the clinical care gap
And in Canada, And in Canada, tootoo
The Evidence….
Chest, 2012;141 (2) (Suppl):53S-70S
The Clinical Gap…
Venous Thromboembolism (VTE) - University of Kansas Hospital
What causes the gap?
• Interactive large-group exercise
What causes the gap?What causes the gap? The evidence-to-practice puzzle
The clinician
The clinician
The evidence/guideline
The evidence/guideline
Health Care
Health Care
System issues
System issues
•PatientPatient
•Team members
Team members
The educational
The educational deliverydeliverysystemsystem
What causes the gap?What causes the gap? The evidence-to-practice puzzle
The clinician
The clinician
Health Care
Health Care
System issues
System issues
•PatientPatient
•Team members
Team members
The evidence/guideline
The evidence/guideline
The educational
The educational delivery/
delivery/ implementation
implementationsystemsystem
Sue: the KU experience
Or: GO Jayhawks!!
The University of Kansas Experience
Interprofessional, Multidisciplinary, Multi-faceted Team Approach
18
Effectiveness of CME, Chest. 2009; 135 (3) (suppl) 49S-55S.
Pathman Matrix of Methods to Change Provider Performance
Methods/ Stages
Awareness Agreement Adoption Adherence
Predisposing VTE Prophylaxis PICC catheter,Cases at Patient safety conferencePodcasts, Signs on unit, Buttons, webinarsResident compliance training, orientation,
Enabling My KU VTE prophylaxis,Departmental Small groups: Trauma, Gen Surgery, ENT, Urology, CTS, Oncology, Ob-Gyn, IM
Nursing Unit Education,Patient EducationAlgorithms
Reinforcing Reminders, Audit/ feedback, other tools
SYSTEMS:Standard Orders Best Practice Alert’s
Results…Sustained Improvement
An educational toolkit
1. Formal CME Lectures, workshops, small
groups
2. Informal education; peer consultation
3. Academic Detailing
4. Print, AV
5. Reminders; audit/feedback
6. Opinion Leaders
7. Patient Strategies
8. Other Strategies and a framework
1) Formal “CME”
• Rounds,• Medical staff meetings• Small group sessions• M&M conferences,
other• NOTE:
– didactic element do not produce changes in performance or health care outcomes
– may be useful to “prime” changes
2) Mentoring/peer consultation
What do you think about these new guidelines, anyway?
• Informal; hallway, phone consults
• Formal consults; letters, etc
• Outreach visits, like ‘academic detailing’
3) Academic Detailing
• +++ RCTs, mostly positive, with moderate effect
• Most often in prescribing behaviors; some in preventive health care
• Sizable growth with PCORI, AHRQ support
4) Print, AV, on-line Materials
includes mailed, unsolicited materials
little/no evidence that such measures, alone, change performance or HC outcomes
May predispose to chanfe
5) Reminders; audit and feedback
Point of care strategies Computerized, paper
formats (EHR permits greater use of both)
Reminders: potentially very effective tools, but note reminder overload
Audit & Feedback: better when data current, comparisons immediate and credible
7) Patient Strategies
generally considered to be patient-education, though exceptions useful
may be delivered in a variety of ways: mailed reminders, patient educational materials, decision aids, wall charts in waiting rooms
Often very effective tools
8) Opinion Leaders
• Several RCTs demonstrate moderate effectiveness (ES: 5-15%)
• OLs= educational influentials=community-identified respected clinicians
• OLs work within the community to effect change
• training required: one part clinical, one part educational
• toolkit useful, adapted for use in a particular community or work setting
Who are Opinion Leaders?
OL Characteristics:(Stross JK– The educationally influential physician Express themselves clearly, provide practical information first and
then an explanation or rationale as time allows, while seeming to enjoy the knowledge that they have
Have a high level of clinical expertise and seem always current and up-to-date
Treat all people as equals; never condescending
Help their colleagues decide among several options, given educationally influential physician’s extended knowledge base
Validate their colleagues’ understanding of new information prompting change in diagnostic and treatment practices
…moreover, Opinion Leaders…
• Should be early adopters of guidelines
• Can be effective “change agents” to eliminate system barriers by revising clinical pathways, protocols or standing orders
• Are enthusastic, informal leaders, and not authority figures or physicians in administrative roles; they work in setting similar to their colleagues and “walk in their shoes”
• Know how to work effectively in their own setting
• Have excellent skills for engaging others to creatively solve problems
Other strategies?
Final points…..
Consider multiple methods Consider sequencing the methods Consider three elements in any
interventions: predisposing, enabling and reinforcing
And a way to organize them…..
the Pathman-PROCEED model
Methods/ Stages
Aware-ness
Agreement Adoption Adherence
Predisposing
Enabling
Reinforcing
National Local
Your turn…• Form groups of 3-5• Choose a clinical topic with which
you’re familiar and in which there’s clear evidence of a care gap
• Analyze the gap: why is it there? What could you propose to close it?
• Develop an implementation scheme, using mostly – not all – educational strategies
Implementing GuidelinesImplementing GuidelinesE-GAPPS WorkshopE-GAPPS Workshopfurther informationfurther information
Sue Pingleton, University of Kansas
Dave Davis, AAMC
