Implementing Guidelines E-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 practice Ideal, evidence-based practice practice clinical care gap The clinical care gap clinical care gap

Examples of the clinical care gap The clinical care gap

And in Canada, too

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 evidence/guideline Health Care System issues PatientPatient Team membersTeam members The educational delivery system

What causes the gap? What causes the gap? The evidence-to-practice puzzle The clinician Health Care System issues PatientPatient Team membersTeam members The evidence/guideline The educational delivery/ implementation system

Sue: the KU experience Or: GO Jayhawks!!

The University of Kansas Experience

Interprofessional, Multidisciplinary, Multi-faceted Team Approach

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Effectiveness of CME, Chest. 2009; 135 (3) (suppl) 49S-55S.

Pathman Matrix of Methods to Change Provider Performance Methods/ Stages Awareness AgreementAdoption Adherence Predisposing VTE Prophylaxis PICC catheter, Cases at Patient safety conference Podcasts, Signs on unit, Buttons, webinars Resident 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 Education Algorithms 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 AgreementAdoptionAdherence 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 Guidelines E-GAPPS Workshop further information Sue Pingleton, University of Kansas Dave Davis, AAMC