Guidelines for Clinical Practice From Development to Use (1992) / Chapter Skim
Currently Skimming:
4 IMPLEMENTING GUIDELINES: CONDITIONS AND STRATEGIES
4 IMPLEMENTING GUIDELINES: CONDITIONS AND STRATEGIES
Pages 83-98
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 83... ...
Chapter 5 discusses how quality, cost, and risk management systems may support and be supported by guidelines for clinical practice.
|
From page 84... ...
This shift takes visible and sometimes controversial form when guidelines for clinical practice move from the development to the application stage, especially when application is backed by formal organizational structures and procedures and by forceful incentives. The ways in which practice guidelines can and do operate as instruments for professional support and accountability are affected by the dynamics of a health care system that is changing and evolving, very often with no particular regard for practice guidelines.
|
From page 85... ...
Eisenberg (1985, 1986) has discussed six sets of activities required for successful alteration of physician practice patterns education, feedback, participation, administrative changes, incentives, and penaltiesand advised that a combined strategy is most likely to be effective.
|
From page 86... ...
. In continuing medical education programs, specialty societies may organize sessions related to practice guidelines they have promulgated.
|
From page 87... ...
The recertification process administered by the American Board of Family Practice includes a review of office records using performance criteria that apparently are not based on formal practice guidelines but that could be (Langsley, 1991~. Some groups, such as the American Board of Internal Medicine, have been considering a role for clinical practice guidelines in establishing criteria either for recertification or for eligibility to apply for recertification, but close links between guidelines and board certification or recertification almost certainly lie well into the future.
|
From page 88... ...
Research on the impact of different educational strategies indicates that personal, interactive strategies tend to be more influential in changing practitioner behavior than are more formal or indirect approaches (Avorn and Soumerai, 1983; Eisenberg, 1986; Chassin, 1988; Soumerai and Avorn, 1990; Siu and Mittman, 1991~. Programs undertaken by respected authorities in the context of ongoing organizational relationships are also effective, and sometimes the involvement of respected leaders may be the key to success or failure of efforts to modify the clinical practice.
|
From page 89... ...
Educational strategies for patients or consumers tend to emphasize impersonal and relatively inexpensive mass information campaigns or to rely heavily on the physician-patient relationship, although this reliance is rarely reinforced by specific reimbursement for patient education (Green, 1991~. At its best, the latter is personal, interactive, ongoing, and decision oriented (if not change oriented)
|
From page 90... ...
. To the extent that automated systems support patient care, such support generally consists of clinical data rather than guidance about appropriate care; generally, it is hospital based and does not extend to the physician's office and similar settings.
|
From page 91... ...
The simplest systems provide medication storage containers with monitors that beep or otherwise alert patients to medication schedules and record use. A telephone-based reminder system for pharmacists is also available (National Council on Patient Information and Education, 1991)
|
From page 92... ...
. Even when the source information is computer based, differences in data storage structures, record identifiers, and coding systems may make information exchange difficult across or within patient care settings (see, generally, Brodnik and Johns, 1991, which includes many of the articles cited here)
|
From page 93... ...
Today, most systems appear to be far less directive than this, but they are likely to change as systems become more sophisticated and as the emphasis shifts from merely providing information to producing desired changes in behavior and outcomes. The committee expects that clinical information and guidelines will become more integrated in such forms as expert rules, normal limits, contraindications, drug interactions, and other supports for decisionmaking (Eckman et al., 1991~.
|
From page 94... ...
, various commercial vendors, and others are increasing the availability of clinical information through on-line literature search systems, floppy disks, and CD-ROM disks.4 To date, these systems appear to include guidelines only incidentally, but this state of affairs is changing as guidelines become more visible (Brightbill, 1990; Frisch, 19911. The Omnibus Budget Reconciliation Act of 1989 requires AHCPR to promote dissemination of guidelines through organizations that represent health care providers or health care consumers, and through peer review organizations, accrediting bodies, and other appropriate entities.
|
From page 95... ...
detailed description of the respiratory care system at the Latter Day Saints Hospital in Salt Lake City, Utah.) · Embedded controls.
|
From page 96... ...
The convergence of financial and clinical management systems motivated by the economic and other pressures described earlier will be a powerful force for moving guidelines into multiple environments, for facilitating comparisons of provider performance and guideline impact, and for feeding back useful information to both developers and users of practice guidelines. The recommendations in Chapter 7 are designed to facilitate and test this proposition.
|
From page 97... ...
are more predictable, and closer to hand, than the behavioral changes. The 6 The IOM has recently completed a study to advise the NLM on new and expanded services for health services research and technology assessment (IOM, l991c)
|
From page 98... ...
SUMMARY Among the supporting conditions for the effective application of sound practice guidelines are educational programs and information and decision support systems. The first is tied closely to the dissemination of guidelines but goes far beyond that one role to promote understanding of the evidence base, rationale, and expected consequences of guidelines.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.