IOM Workshop on Standards for Clinical Guidelines Monday, January 11, 2010 Elizabeth Mort, MD, MPH Massachusetts General Hospital Partners HealthCare, Inc.

2  Integrated, academic health system founded in 1994 by Brigham and Women’s Hospital and Massachusetts General Hospital  Four-part mission is patient care, teaching, research, and community service  1.7 million patients receive care from Partners institutions and physicians  170,000 hospital inpatient discharges annually  4.3 million outpatient and physician visits annually  We are a large consumer of clinical guidelines Partners HealthCare, Inc.

3 Partners HealthCare Hospitals Martha’s Vineyard Hospital Nantucket Cottage Hospital Rehab Hospital of the Cape and Islands Faulkner Hospital Newton- Wellesley Hospital McLean Hospital Massachusetts General Hospital Spaulding Rehabilitation Hospital Shaughnessy- Kaplan Rehabilitation Hospital North Shore Medical Center - Union North Shore Medical Center - Salem Non-Acute Hospital Acute Care Hospital H Brigham and Women’s Hospital Partners HealthCare

4 Role of guidelines at Partners HealthCare, Inc Goal is to assure that all patients get the highest quality care, reliably delivered anywhere in the system.  Identify priority areas for system-wide improvement.  Review clinical guidelines using clinical experts and develop system-wide approaches.  Implement guidelines using high reliability design, leveraging system resources such as electronic medical record, registries, clinical decision support rules, etc.  Measure compliance transparently and study failures/variance.  Refine as needed

6 Recommendations for guideline standards 1.Concur with many of the presenters today that describing the level of the evidence and the strength of the recommendation is critical. Agree with developing a standard taxonomy to simplify. 2.Describe the exact nature of and the probability of obtaining the benefit and risks. (Allows prioritization of action at all levels, from the system to the individual patient.) 3.Highlight areas of controversy. 4.Develop an organized, transparent, accountable, and safe approach to provide consensus opinion and expert opinion on the management of populations or situations that are not explicitly addressed in the clinical practice guidelines. 5.Provide guidance to facilitate implementation if available and suggest performance measures if appropriate.

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8 Additional FAQs – Care of the elderly, pts with renal failure, who have CHF, what about CDEs, etc.

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12 Include guidance on implementation: STEMI Bradley, E. et. al; Reducing door-to-balloon times to meet quality guidelines: How do successful hospitals do it? Circulation 2004

13 Time for staff to arrive: 35 min Triage Time: 10 min Lab arrival to reperfusion: 30 min. DTB can be < 80 minutes DTB can be < 80 minutes Include guidance on implementation: STEMI Bradley, E. et. al; Reducing door-to-balloon times to meet quality guidelines: How do successful hospitals do it? Circulation 2004

14 Recommendations for guideline standards 1.Concur with many of the presenters today that describing the level of the evidence and the strength of the recommendation is critical. Agree with developing a standard taxonomy to simplify. 2.Describe the exact nature of and the probability of obtaining the benefit and risks. (Allows prioritization of action at all levels, from the system to the individual patient.) 3.Highlight areas of controversy. 4.Develop an organized, transparent, accountable, and safe approach to provide consensus opinion and expert opinion on the management of populations or situations that are not explicitly addressed in the clinical practice guidelines. 5.Provide guidance to facilitate implementation if available and suggest performance measures if appropriate.