Guidelines for Clinical Practice From Development to Use (1992) / Chapter Skim
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3 IMPLEMENTING GUIDELINES: OVERVIEW AND ILLUSTRATIVE CASES
3 IMPLEMENTING GUIDELINES: OVERVIEW AND ILLUSTRATIVE CASES
Pages 65-82
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From page 65... ...
The time horizon extends from the near to the indefinite future; the number of involved parties multiplies; responsibilities blur; var ~ The Omnibus Budget Reconciliation Act of 1989 gave primary responsibility for establishing a public program to develop and promote practice guidelines to the Department of Health and Human Services, through the Agency for Health Care Policy and Research and its Forum for Quality and Effectiveness in Health Care. Necessary steps for implementing this program include hiring staff, developing a program agenda, letting contracts, convening and assisting expert panels, establishing an advisory council for AHCPR, and generally establishing and administering a broad, ongoing federal program.
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From page 66... ...
The focus of guidelines for patients, therefore, is likely to be educational for example, handbooks or brochures about proper care for a given ailment, appropriate preventive regimens, or when to seek professional health care and when to manage one's own care. Keeping an overview of implementation reasonably compact but illuminating is difficult, given the scope and variety of implementation efforts, on the one hand, and the lack of systematic literature about the topic, on the other.
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From page 67... ...
The cases are intentionally simplified portraits designed to convey some, but by no means all, of the real and practical issues in the effective use of guidelines. They are not intended to portray uniformly flawless application of impeccable guidelines to achieve specifically desired results, nor can they provide the depth of description and analysis possible with true case studies.
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From page 68... ...
CASE STUDIES Case Study 1: Small Internal Medicine Practice KEY WORDS: patient needs, characteristics, and preferences; conflicts between perceived patient needs and guidelines; specificity and format of guidelines; utility of computer-based information and decision support systems; time constraints; hassle factor Dr. Marcus practices in a typical setting: a small (in this case, five-person)
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From page 69... ...
Dr. Marcus appreciates that some review organizations have made an effort to minimize the burdens on physician offices and to employ clinically knowledgeable reviewers and clinically respectable review criteria; unfortunately, other organizations are less well managed.
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From page 70... ...
In particular, little consistent advice was available about when to refer marginally symptomatic patients to psychiatrists or clinical psychologists, or about when to manage patients in ambulatory versus inpatient settings. The issue was significant for three reasons: the membership comprises mainly families, so the plan covers a considerable number of adolescents; adolescent mental disorders are rising in prevalence; and the employers with which CC contracts were becoming alarmed at the proportion of expenditures for these conditions.
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From page 71... ...
In general, however, the plan prefers not to take a punitive approach but to use guidelines as part of an information feedback process and as screens for selecting participating physicians. Because appropriate use of established procedures and services, such as tonsillectomy and hysterectomy, often depends on a variety of patient-specific circumstances, Dr.
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From page 72... ...
Although UMCH has invested substantial levels of resources in identifying administrative problems that lead to errors and practice variations, the institution has also devoted considerable effort to feeding back statistical information to physicians in ways that encourage more consistent practice without relying on punitive measures or embarrassment. As a case in point, when information showing the distribution of specific physician practices (e.g., days following major surgery before a patient is ambulated, preferences for certain kinds of antimicrobial agents, lengths of stay for particular conditions)
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From page 73... ...
Pierce has seen physicians become much more interested in information that will help them build a record of practice quality and efficiency that will attract invitations to participate in managed care plans and similar networks. One of the keys to UMCH's quality improvement program is its very sophisticated computer-based information and decision support system, which not only provides a great deal of institutional data but also integrates a variety of practice guidelines in different formats.
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From page 74... ...
Memorial Hospital has a traditional utilization review and quality assurance department that bases most of its activities on retrospective reviews of samples of patient charts, which are judged against common "generic screens." However, Dr. Houlihan prevailed on the QA coordinator to institute a special, concurrent study of all adverse events related to the surgery and anesthesiology departments.
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From page 75... ...
It also serves as an inpatient care unit for a local hospice program. It is a private, nonprofit, nonsectarian organization affiliated with University Hospital Medical Center (case study 3~.
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From page 76... ...
Once orders are initialed by a physician, they can be implemented within the specified ranges as needed by the hospice nursing staff. Physicians are not required to accept or use the guidelines, but if they do not, hospice nursing staff must telephone them to obtain authorization for each change in medication, dosage, timing, or route.
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From page 77... ...
Her indecision is a function of the conflicting guidelines, the apparently careless and possibly acquisitive behavior of Dr. Frank, the confusion surrounding the results of the follow-up mammogram, and the time and money involved.
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From page 78... ...
In the case studies, the clinicians at University Hospital Medical Center, Memorial Hospital, and Mapletown Home work in worlds that offer
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From page 79... ...
Environmental factors include the prevalence and incidence of disease and illness, the composition and capability of the overall system of health care delivery, government regulations, the medical liability system, and the nature and extent of social consensus about matters affecting health care decisions and behaviors. In the nursing home setting, exposure to detailed federal regulation and inspection in a resource-constrained and sometimes bleak environment has evidently left Dr.
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From page 80... ...
practitioner conformity with these guidelines. These methods might include provision of written information, education sessions using professional opinion leaders, feedback of comparative information on individual practice patterns, application of some form of utilization review, or perhaps reduction in the payment differential for vaginal delivery versus cesarean section.
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From page 81... ...
This context includes educational activities and information systems as well as structures and processes to assess and assure quality of care, to manage health care costs, and to reduce medical liability. SUMMARY This chapter has provided an overview of some factors that affect the implementation of clinical practice guidelines.
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From page 82... ...
across the main departments of an institutional provider; the role of top management; quality of care, quality assurance, and continuous quality improvement; risk management and liability; computer-based information and decision support systems; a myriad of elements relating to the local development, adaptation, and implementation of guidelines; and simple human error. External factors include the existence of conflicting guidelines, insurance benefit plans and coverage policies, requirements concerning preprocedure review, limited institutional or community resources, and local, state, and federal regulation.
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