1Pressure Ulcers: Changing Occupational Therapy Practice Jeanette Boily & Linda BoronowskiHealth Care Innovations Conference and Trade Show December 2, 2009; CalgaryThank you for attending our presentation on Pressure Ulcers: Changing Occupational Therapy Practice.My name is Linda Boronowski and I work as a Practice Coordinator for the Acquired Brain Injury and Spinal Cord Injury programs at GF Strong Rehabilitation Centre in Vancouver. I would also like to introduce Jeanette Boily who works as an OT Practice Coordinator for Gerontology at Vancouver General and the University of British Columbia hospitals.We are part of a group of occupational therapists who facilitated the development of an Occupational Therapy Skin Care Guideline for Vancouver Coastal Health and Providence Health care on the prevention and treatment of pressure ulcers.This presentation includes some background on how the guideline was developed, its content and application in practice by clinicians across various work settings.We would like to know a little bit about you our audience?Please raise you hand if you are an:Occupational TherapistMedical Equipment SupplierNursePhysiotherapistOtherThank you!
2Vancouver Coastal Health & Providence Health Care Yellow AreasVancouver Coastal Health and Providence Health Care are shown here as the yellow portions on the map.You can see that it includes a fairly large geographical area.Occupational Therapists work in many different practice settings in both rural and urban areas.
3Practice IssueOccupational Therapists in Vancouver Coastal Health & Providence Health Care identified concerns regarding variability in their practice of skin care.The areas of concern were assessment, prevention and management of pressure ulcers.This project evolved from a frontline conversation in the spring of 2005.Occupational Therapists identified variability in their practice of skin care across different settings in our health region.They also expressed :frustration with role expectations andthe need for support for best practice.At the same time, work was being done by nursing on an inter-disciplinary wound care guideline and yet, no occupational therapists had been invited to join this committee.
4The ChallengeHow to bring a large number of occupational therapists involved in skin care management together across the region to develop consistent practice?Our Challenge was:How to bring a large number of occupational therapists involved in skin care management together across the region to develop consistent practice?
5The Football Huddle Purpose of a huddle: Coach and players identify strategiesA plan will be adapted to the situation on the fieldMake the most of limited time and to determine actionsInitially, the VCH Director of Professional Practice for Allied Health pulled together a team of interested participants.Occupational Therapists with expertise representing different regional and practice areas formed the core planning group.The plan was to include frontline clinicians involved in skin care in the development of this project.We reflected on the huddle used in football and felt the principles of the huddle could assist with the planning for this project.In the football huddle, the coach and players meet to strategize the play using evidence, expert knowledge, and experience.The plan is adapted to the situation depending on what is happening in the field andThe huddle is time limited and action orientedThe game must go on.
6The Practice Huddle Purpose of an OT practice huddle? OTs identify evidence-based practiceDevelop a plan that applies to all areas of therapy and sitesTime limited project with frontline OT’s creating a best practice guidelineThe occupational therapy huddle would bring together staff with expertise representing various practice areas.The group would discuss and review evidence - based practice and options.They would develop a plan and facilitate implementation of best practice in all areas of clinical care.A time limited project seemed feasible.The occupational therapy practice huddle seemed to be a catchy title and it was hoped that it would attract the attention of OTs to participate in this project
7GoalTo develop a guideline for use as a clinical reasoning tool versus an answer guide for occupational therapists new (and old) to this area of practiceOur goal then was :To develop a guideline for use as a clinical reasoning tool versus an answer guide for occupational therapists new (and old) to this area of practice.
8Timeline Evaluation Evaluation June ‘09 Implementation Roll out September ‘08ApprovalHAIAC March ‘08Huddle 3 Sept ‘07The process of developing this Guideline included:three practice huddles with OT clinicians in November 2005, October 2006 and September 2007.The primary focus of these huddles was to review available evidence and validate the guideline.consultation with the Vancouver Coastal Health OT Practice council, andapproval by the Health Authority Interdisciplinary Advisory Council.Throughout, this process has been inclusive of frontline OTs and feedback has been sought to enhance the document.ReviewOT Council April ’07 &Jan 08Huddle 2 Oct ‘06DevelopmentHuddle 1 Nov ‘05Identified Need Spring ‘05
9Guideline Development Guideline was developed using:Research evidenceExisting interdisciplinary guidelinesNational Institute for Health and Clinical Excellence (NICE) modelConsensus from occupational therapistsPractice guidelines are developed on the best evidence available. Unfortunately, we do not have randomized controlled trials for all areas of our profession, so we have to rely on some other forms of evidence to guide our practice. It became apparent that although there are interdisciplinary guidelines that offer strong evidence for skin care, there was not strong evidence specific to occupational therapy practice.The Occupational Therapy Skin Care Guideline was developed using:research evidence,existing interdisciplinary guidelines from the National Institute for Health and Clinical Excellence (NICE) / Registered Nurses Association of Ontario (RNAO) / University of Iowa Gerontological Nursing / and the Wound, Ostomy & Continence Nurses Society.Often these guidelines would say ask or refer to an Occupational Therapist and we wanted to fill in the blanks.and consensus from occupational therapists with expertise in pressure ulcer prevention and treatmentWe decided to adapt the NICE (National Institute for Health and Clinical Excellence) quick reference guide as the basis for our schematic.Levels of evidence for individual recommendations in the OT Skin Care Guideline are not listed in order to improve the readability & flow of the document. We decided to use the “ Quick reference guide for the Treatment and prevention of pressure ulcers” as a levels of evidence resource. This table summarizes the strength of evidence for specific recommendations within the Registered Nurses Association of Ontario (RNAO) guidelines and the source is an article by Keast, DH et al. (2006). Best Practice Recommendations for the prevention and treatment of pressure ulcers: Update Wound Care Canada, 4 (1), ppThe table was copied and used with permission from the publisher.
10Guideline Content Schematic Best Practice Recommendations Assessment Care PlanOccupational Therapy InterventionAppendicesThe main sections of the document are the schematic, best practice recommendations and the appendices.The schematic serves as the starting point and forms the base for development of the guideline.The bulk of the document includes best practice recommendations and practice tools for assessment and intervention.The Guideline components are intended to be considered in the context of the whole document and it is not recommended that separate pages be used as stand alone documents.
11Please refer to your handout so that you are able to read the schematic of Best Practice for the prevention and treatment of pressure ulcers.It is designed to provide an overview of the process for assessment and intervention specifically for occupational therapists. The schematic demonstrates a process of care, and like many occupational therapy models, it is not a linear approach. It flows through assessment, documentation, care planning and intervention followed by the critical reassessment phase that loops back to the beginning. For example, the left side incorporates the best practice for assessment while the right sides offers specifics for occupational therapy intervention.The schematic emphasizes inter-professional responsibilities for risk assessment and skin assessment, and focuses on occupational therapy’s contributions to the inter-professional care plan. It is very important to emphasize that the occupational therapist is part of a greater team. OT involvement is context-dependent and will differ in various settings and with different models of practice.The best practice guideline follows the flow of practice shown in the Schematic.Tools and resources are included under the schematic headings and are intended to enable occupational therapists to incorporate the recommendations into their own practice.
12Major ThemeHolistic assessment, management and intervention are the responsibility of the inter-professional teamWith the development of these guidelines, the importance of teamwork stood out.There was very strong evidence which resulted in the overarching best practice statement for the whole document:Holistic assessment, management & intervention are the responsibility of the inter-professional team.The role of the occupational therapist will differ depending on the clinical practice setting and each practice area should develop a clear understanding of interdisciplinary roles for skin assessment, management and intervention.
13Risk Assessment Identify Vulnerable Clients Access information from the interdisciplinary recordsPerform risk assessment and repeat on a regularly scheduled basis, or when there is a significant change in the individual’s condition.Occupational Therapists should identify vulnerable clients and complete a risk assessment on their entry to the healthcare setting.Vulnerable adults may include clients who:Are restricted to bed and/or chairHave vulnerable areas and / orDemonstrate mobility issuesTherapists should perform the initial risk assessment or access information from the risk assessment completed by a team member.Guidelines in the literature state that these risk assessments should occur at different time intervals depending on the setting:Acute care: Perform initial assessment at admission and reassess at least every 48 hours or whenever the patient’s condition changes.Long-term care: Perform initial assessment at admission. Reassess weekly for the first 4 weeks, then quarterly after that, and whenever the resident’s condition changes.Home-health care: Perform initial assessment at admission and when there are risk factors, reassess every visit.
15Braden Scale Braden Score for Pressure Ulcer Risk Screening tool to assist in identifying patients at riskPredictive validity of cut off scores varies across different populations:16 for acute care settings18 for nursing home residents19 for home health patientsCut-off scores vary across different populations for prediction of risk. For example:16 and below predicts high risk for acute care settings18 and below predicts high risk for nursing home residents and19 and below predicts high risk for home health patientsWhen the frequency of monitoring is low, the risk will likely increase.Risk screening tools such as the Braden are useful aids to structure assessment and documentation.The literature stresses the importance of using risk assessment tools and scales as an adjunct to, but not a replacement for, clinical judgment. Regular skin assessment for early signs of injury is an essential adjunct.From: Predicting Pressure Ulcer Risk: Using the Braden scale with hospitalizedolder adults: the evidence supports it. AJN November Vol. 107, No. 11(PDF available at
16Risk FactorsPerson Previous skin breakdown Sensory impairment Decreased consciousness Cognition Pain Psycho-emotional status Decreased mobility Deformity, muscular atrophy Posture Nutrition/hydration status Incontinence Positioning preferences Extremes of ageEnvironment PressureShearingFrictionMoistureSocio-economic statusSupport surfaces during 24 hour periodFrom an Occupational Therapy point of view, Risk factors could be grouped as;PersonEnvironmentAnd OccupationMost of these factors are included in an OT assessment and potentially in the OT Data Base.However, they are approached from a different perspective and with different goals relative to skin care.OccupationLifestyle choicesCaregiver supports
17Skin Assessment Best completed by interdisciplinary team OT needs to access information required for clinical reasoning / problem solving processInspect all vulnerable areas for: Persistent erythema; Non-blanching redness; Purplish / bluish localised areas, blisters, localized heat, coolness, oedema, or induration, & skin breakdownSkin Assessment is best completed by an interdisciplinary team which may include the physician, nurse, physiotherapist, dietitian, etc..OTs need to seek out or access this information through observation of the wound and assessment of the skin, review of nursing documentation, or on a joint team visit to assess the client.Things to look for may include; Persistent erythema; Non-blanching redness; Purplish / bluish localised areas; Blisters; Localised heat; Localised oedema; Localised induration ( hardened area); Localised coolness if tissue death occurs; Skin breakdown noting location, possible cause(s), and wound status.Occupational Therapists need to use the same terminology as other team members when describing wound staging and wound healing as described by the National Pressure Ulcer Advisory Panel.
18Record Assessment OT Skin Care Risk Assessment Form Template Risk factorsCommentsCare Plan Triggered?Date/ InitialsPrevious skin breakdown Yes NoSensory ImpairmentDocumentation of the assessment noting all relevant risk factors is essential.A Skin Care Risk Assessment Form, Template and Guideline was developed to assist OTs with documentation.The assessment form can be used as is, or as a template for a service specific assessment form.The first column of the form lists risk factors identified in the Occupational Therapy Skin Care Best Practice Guideline.The third column is used to identify factors that require occupational therapy intervention.This information may be documented in an occupational therapy or interdisciplinary progress note or care plan.Where the care plan is triggered, the interdisciplinary team will need to develop and follow steps to address the associated risk factors, as related to goals of care.
19Record Assessment Sensory impairment Sensory impairment? Where? Client awareness of impairmentDoes the client compensate during functional activities? For example, uses hand to check for rough surfaces before putting on shoe.Cues for the comments column or column 2 are included in t he guideline for this risk assessment documentation form.These cues include prompts and questions that may help to identify the specific factors that place the individual at risk for skin breakdown or contribute to wound development.For Example Sensory Impairment includes the following promptsSensory impairment? Where?Client awareness of impairmentDoes the client compensate during functional activities? For example, uses hand to check for rough surfaces before putting on shoe.Does the client/caregiver regularly check the skin visually?This information is intended to be recorded under the comments section.Does the client/caregiver regularly check the skin visually?
20Care Plan Considerations Sensory Impairment Teach client to visually checkTeach effective weight shiftingCreate a positioning scheduleProvide equipment, or teach techniques to compensate for sensory impairment during functional activitiesTeach the consequences of skin breakdownUsing risk and skin assessment findings, an inter-professional care plan should be developed for clients with pressure ulcers or vulnerable to skin breakdown.The care plan considerations section of the guideline includes a box for each risk factor.For example : the sensory impairment area is shown on the screen.This is by no means meant to be an exhaustive list, but rather a tool to assist the clinician in creating a thorough care plan.It is expected that each service area will have their own unique format for care planning.
21OT interventions Professional Practice Communication Education NutritionRepositioning/TransfersSupport SurfacesPositioning schedulesPainMoistureNow we are moving deeper in to the body of the document to Best Practice Recommendations for OT intervention.Any intervention must take into consideration the identified risk(s) and causative factor(s) of the skin breakdown.Once identified referrals should be made to interdisciplinary team members as appropriate.Best practice recommendations for intervention fall under the categories of:professional practice,communication,education,moisture,nutrition,positioning schedule,repositioning/transfers,support surfaces, andpain.Interventions must be evaluated for their effectiveness in preventing and treating pressure ulcers through such mechanisms as ongoing client monitoring and identifying the client/equipment variables that may lead to best skin care outcomes..
22OT interventions Example: Positioning Schedule Consider all support surfaces throughout the 24-hour period, causative factors, and environmental limitations.Participate in creating a 24-hour schedule for persons vulnerable to skin breakdown or with existing pressure ulcers.This is an example of the content of OT intervention Best practice recommendations.Some of the strongest evidence is related to development of a positioning schedule.A few of the major points about positioning schedules reviewed in this guideline are:Consider all support surfaces throughout the 24-hour period, causative factors, and environmental limitations.Participate in creating a 24-hour schedule for persons vulnerable to skin breakdown or with existing pressure ulcers.Consider position changes consistent with activities of daily living (ADL) routines and lifestyle choices. Consider acceptability and needs of the person and care providerIn bed turn at least every 2-4 hours on a pressure-redistributing mattress or at least every 2 hours on a nonpressure-redistributing mattress. In chair, reposition every 15 minutes if client is independent with weight shifting or every hour if assistance is required.For bed acquired pressure ulcers, minimize the time spent in bed (weight bearing on that skin surface); for chair-acquired pressure ulcers minimize time spent sitting on the ulcer.
23OT interventions Example: Support Surfaces Consider use of full electric hospital beds and tilt-in-space sitting surfaces so the person and care giver can reposition for pressure redistribution and comfort.Reclining chairs and reclining wheelchairs increase the risk of friction and shearing and so should be avoided.A few of the major points about support surfaces reviewed in this guideline are:Consider use of full electric hospital beds and tilt-in-space sitting surfaces so the person and care giver can reposition for pressure redistribution and comfortReclining chairs and reclining wheelchairs increase the risk of friction and shearing and so should be avoided.For weight shifting in chair or wheelchair, unweighting using arms may be inadequate, consider using forward flexion or side-to-side distribution instead if balance is sufficient.Research to date rarely identifies specific makes and models of support surfaces equipment.Do not use donut type devicesPressure mapping may be useful tools to determine if adequate pressure redistribution is achieved.Clinical reasoning must be factored into the decision-making.
24Repeated negative outcome MonitorIs the skin intact?Is healing occurring?Are there new or recurring wounds?Is moisture a problem?Is mattress set up and used as needed?Is the person able to sustain multiple positions or adjust posture to avoid prolonged weight bearing on at risk area(s)?Positive OutcomeContinue to monitor skin integrity and wound healing regularlySelect support surface with limited resistance to immersion and low shearConsider products featuring a fluid (air*, water*, viscous fluid*) to allow immersion of the person into the support surface, to optimize envelopment and to decrease tissue shear strainCan be powered, non-powered or zoned support surfacesKey setup consideration - Assess for bottoming outDoes the mattress provide adequate immersion in supine, side-lying and, in sitting if the head of the bed needs to be elevated for activities such as eating sitting up in bed?NoSelect support surface that offers minimal immersion* and envelopment*Consider products that help redistribute* pressure over the contact areas of the person’s bodyCan be made of a solid* material that does not flow perceptibly under stress such as viscoelastic* foamYesNegative OutcomeReviewRelated care planSupport surface selection and setupRepeated negative outcomeWith the interdisciplinary team, review treatment goals and plan of careThe Intent of the decision trees is:-To illustrate the intervention process and-To generate equipment description to best fit the clients’ level of risk and skin protection needsHere is an example of a decision tree designed to address mattress and overlay support surfaces.The decision trees do not refer to specific products. The intent is to generate equipment descriptions based on identified parameters. These allow the occupational therapists to explore the broad range of products available to best fit the person’s level of risk.To better understand what equipment matches the product parameters, it is suggested that the occupational therapists engage in a dialogue with a medical equipment vendor, view manufacturer’s websites and critically analyze products available.
25OT intervention Grey Box Example: Equipment Considerations: Shear Shear is a mechanical force that moves the overlying skin and soft tissue in an opposite direction to the underlying bony structures. This can result in breakdown of skin from the inside out.A common example of shear strain occurs during raising/lowering of the head of the hospital bed. In this example, skin overlying the trunk and pelvis “sticks” to the mattress as deeper tissues and structures (e.g. spine and pelvic girdle) move in the opposite direction. In this scenario, it is common to see skin breakdown over the coccyx and sacrum.A wound caused by shear forces can appear irregular or elongated in shape.How to minimize shearShear is minimized by enabling skin and body structures to move in the same planeGrey Box Example:SHEARGrey boxes are included throughout the document to further define concepts and illustrate basic principles.They cover topics such as pressure, friction, shear, postural needs, functional demands, monitoring / follow up, etcThe grey boxes include:-A definition-Equipment and/or intervention considerations
26OT intervention Factors increasing the need for monitoring : The greater the risk of skin breakdown,the severity of the woundand the complexity of the interventionRole of OTActive problem solver in implementation phaseEnsure appropriate set-upDevelop an explicit monitoring planMonitoring is the action of observing a situation for any changes, positive or negative, which may occur over time. The greater the risk for skin breakdown, the severity of the wound and/or the complexity of intervention(s), the more monitoring will be required.How is the occupational therapist involved in monitoring?The occupational therapist has active involvement in the implementation phase. Catching and solving problems early can prevent serious setbacks. When providing a new piece of equipment, the occupational therapist is responsible for ensuring the appropriate selection and setup. This may involve a daily check to troubleshoot and demonstrate the use of equipment.Once the intervention is seen to be effective, there is greater reliance on the person and/or primary care provider(s) to continue monitoring. The occupational therapist must ensure that the person and care provider(s) clearly understand expectations.A monitoring plan should be made explicit in the care plan and responsibilities assigned for each component. It should be reviewed to reflect changes along the continuum of provision of care to a person in order to prevent skin breakdown and/or to promote wound healing..
27ReassessmentReassess risk on an ongoing basis and, in particular, if the person’s circumstances changeReview intervention in response to altered level of risk, condition or needsParticipate in a review of the interdisciplinary care planOccupational therapists should reassess risk on an ongoing basis and, in particular, if the person’s circumstances change. Intervention should be reviewed in response to an altered level of risk, condition or needs. Occupational therapists should also participate in a review of the interdisciplinary care plan.
28Appendices Glossary of terms Grading levels of evidence Braden Scale Assessment, Care plan, & Intervention toolsReferences, Search strategies, & BibliographySeveral appendices have been included as a part of the Skin Care GuidelineAppendix 1 is a Glossary of terms which provides definitions for many skin care terms used in the document. Definitions taken from the National Pressure Ulcer Advisory Panel. Knowledge of terminology is essential for occupational therapists to effectively communicate with team members.Appendix 2 explains how levels of evidence are gradedWith respect to the levels of evidence it was elected to not include this information within the body of the guideline to improve the readability and the flow of the document. However, as it is the backbone of the work, the information regarding the strength of the evidence in the form of a table is included. This was taken from the Best Practice Recommendations for the Prevention and Treatment of Pressure Ulcers: Update Wound Care Canada. These reflect the strength of evidence for specific recommendations within the Registered Nurse Association of Ontario guidelines.As said earlier, where higher levels of evidence for occupational therapy practice could not be found, level five evidence from clinical experts was used.Appendix 3 – Braden ScaleAppendix 4 – Skin Care Risk Assessment guidelines & templateAppendix 5 – Care Planning ConsiderationsAppendices 6, 7, 8 – Decision TreesAppendix 9 – Practice Guideline ReferencesAppendix 10 shows the search strategies employed for finding evidence for best practice in this practice area.Finally, Appendix 11 is a bibliography which includes all the resources that were consulted for the development of this Guideline.
29Timeline Re-evaluate Knowledge Translation Knowledge Broker Project May 09Back to our timeline.This has not been a short term project---a quick fix. Remember we had our first huddle in November 0f 2005We began implementation nearly 3 years later.EvaluateEvaluationJune ‘09ImplementRoll out September ‘08
30Awareness Agreement Adoption Adherence From Paper to Practice (Pathman, Konrad, Freed, Freeman & Koch, 1996)The development of a clinical practice document is a the first step towards changing clinical practice. Once developed it was critical that we develop a plan to support therapists in knowledge translation into every day practice for it to be worth the paper it was printed upon.In 1996, Pathman and his group proposed a model to explain a sequence of cognitive/behavioral steps whereby new medical knowledge affects physicians behaviour. They presented that first physicians must become aware of new knowledge, agree with it, decide to follow it and then actually do it. Failure to progress along the pathway leads to “non-compliance” with the recommendation.
31Awareness Distribute Guideline: OT leaders Skin Care champions Wound Care nursesElectronic accessUse local networking to create a buzz:Rounds, staff meetings, informal discussion groupsIn order to raise awareness of this new OT guideline we took several approaches to disseminate the information. In September 2008 we enlisted the support of the occupational therapy practice leaders as well as on-site clinicians who had a passion for the area of skin care, Using a coaching approach, each local champion had in-services on the guideline to familiarize clinicians with it content.We also started to share our guideline more widely by posting on policynet (a section of the VCH website) and sharing with a group of wound care nurses to encourage discussion of the potential of occupational therapy contribution.Where ever possible local champions were encouraged to create a buzz about this new guideline.
32Charge to the Champions Familiarize yourself with the GuidelineStart conversations about roles and responsibilities on your unitsIdentify gaps in your own practiceTake advantage of educational resourcesThe implementation of this Guideline will look different across different work sites.This is where consultation with your OT practice lead and your team will be requiredFirst steps could include:Familiarizing yourself with the GuidelineStarting conversations about roles and responsibilities on your unitsIdentifying gaps in your own practiceandTaking advantage of educational resources
33Agreement Opinion leaders (champions, huddle participants, clinicians) Identify knowledge, skills, attitudes.We completed survey asking about the guideline’s applicability to occupational therapy practice and to barriers to implementation. Overall it was very positive but but therapists identified barriers to its implementation. Some of these included their own knowledge or lack there of and insufficient resources such as lack of equipment and time within heavy caseloads..A future consideration may have been to identity more specifically the knowledge, skills, and attitudes of the occupational therapists to assess their needs before implementation.
34AdoptionDepends on the service delivery model, team clarity and agreement on roles and responsibilities, equipment availableCan’t do everything at once; choose pieces that are most likely to succeedIt was very clear that each practice setting would need to develop its own plan for implementation. Factors such as the service delivery model, clearly defined roles and agreement among teams and varied resources would have influence the plan. The guideline encompasses the entire process of care and it was acknowledge that it would have been daunting to start doing the whole thing in its entirety. For this reason, therapists were encouraged to pick pieces of it that they could focus on that were likely to succeed.
35What is likely to succeed ? Processes that:Show an advantageAre compatible with current practicesAre relatively less complexAre easy to trialCan see resultsWe encouraged therapists to focus on processes that Show an advantageAre compatible with current practicesAre relatively less complexAre easy to trialCan see results
36Adherence/sustainability This is a multi-factorial, complex area of practiceThe processes for implementation are not clear cut nor straight forwardProblem-solving, creativity, garnering resources and supports will be requiredThis will be an ongoing process of evaluation and developmentThe final “A” of the Pathman model Adherence is very austere suggesting one single approach is necessary. Skin care is multi-factorial and a complex area of practice. Also with the diverse practice settings and populations the implementation plan would not be clear cut or straight forward. Rather it is a process that is evolving.In order to fully realize the full potential of this areas of occupational therapy practice it will require local roblem-solving, creativity. Development of additonal supports and resources will be required.Additionally, we acknowledge that the evidence is also evolving and we will need to continue to review the literature to incorporate into the guidelines. Initially we had indicated that this process should take place every 2 years so that the most current recommendations would be included in the guideline.
37Lessons LearnedCore group of leaders for consistency and follow throughFrequent communication to maintain momentum and interestPermission to make mistakes and learn as you goAlignment with organizational values and prioritiesAssumptions about what a guideline is and what it takes to produce one were different initially-egg. Depth of literature review and how to deal with limited research in this areaDiffering assumptions and expectations about skills required to do the project- egg. Therapist skill in evaluating level of evidence in the literature.Need for ongoing communication throughout the process to ensure that you keep therapists involved, excited, and on time targetsNot a quick fix – project takes timeGood to have target datesLeadership – identified, consistent, team leaders for groups Back-fill to allow leaders to engage in the project