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Regional Implementation of Guidelines: Insights and Strategies

Explore pearls and pitfalls of regional guideline implementation, from understanding variation to effective strategies, with Dr. Dave Davis at the E-GAPPs Conference in December ‘12.

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Regional Implementation of Guidelines: Insights and Strategies

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  1. E-GAPPs conference, December ‘12 Regional Implementation of Guidelines: pearls and pitfalls Dave Davis, MDSenior Director, Continuing Education & Improvement, AAMC

  2. Assumption: regional implementation depends on understanding regional variation…. • Nothing to disclose (sort of sad, huh?) • My perspective • Acknowledgments: David Longnecker, MD, AAMC; GIN colleagues; Guidelines Advisory Committee, Ontario • Another assumption: Pearls • Pitfalls = 1

  3. Framing the talk… • Variation in practice: the clinical care gap from national and local levels • What causes the variation? • Within this framework, what have we learned about effective (and maybe not effective) implementation strategies? • Are there forces driving these strategies? • So what? Implications for CPGs; the AAMC’s initiatives in this space

  4. Framing the talk… • Variation in practice: the clinical care gap from national and local levels • What causes the variation? • With this framework, what have we learned about effective (and maybe not effective) implementation strategies? • Are the forces driving these strategies? • So what? Implications for CPG

  5. Country-country comparisons

  6. And for this expenditure, what do we get?

  7. Within-country variation: US 2008 Dartmouth data

  8. Dartmouth Atlas 2008…

  9. Canadian variation • Canadian Institute for Health Information • “regional variations in C Section rates point to underlying differences in care delivery”

  10. Framing the talk… • Variation in practice: the clinical care gap from national and local levels • What causes the variation? • With this framework, what have we learned about effective (and maybe not effective) implementation strategies? • Are the forces driving these strategies? • So what? Implications for CPG

  11. What causes the variation? Health professional/ Clinician issues Evidence, guideline, clinical message Health system issues (funding, workforce, data, EHR, policies) Educational message delivery system

  12. Framing the talk… • Variation in practice: the clinical care gap from national and local levels • What causes the variation? • Pearls & Pitfalls: within this framework, what have we learned about effective (and maybe not so effective) implementation strategies? • Are the forces driving these strategies? • So what? Implications for CPG

  13. Using the variation…. • PEARL/PITFALL #1: consider/use the environment: • training capacity, existence, emphasis • health professional mix and skill set • re-certification & other clinician levers • current policies, regulations • accreditation standards and requirements • culture Evidence, guideline, clinical message Clinician issues health system issues (funding, workforce, data, EHR, policies) Educational, message delivery system

  14. The “Typical” academic medical center* AAMC’s IQ & ae4Q initiatives *there’s no such thing QI/PI programs Staff development EHR Health system data Com-munity Teaching Hospital UME/ GME Faculty Devel’t Accreditation, other input

  15. Using the variation… • P/P#2: • tailor-make/adapt the guideline • adapt language to local norms • use quality measures • develop patient tools • other… Evidence, guideline, clinical message Clinician issues health system issues (funding, workforce, data, EHR, policies) Educational, message delivery system

  16. What causes the variation? Evidence, guideline, clinical message Clinician issues health system issues (funding, workforce, data, EHR, policies) Educational message delivery system

  17. P/P #3: (not)paying attention to the research in CME/CPD - some findings…

  18. dissemination P/P#5: thinking that lectures will change outcomes? Just plain dumb….

  19. P/P#6: don’t forget other educational interventions…

  20. P/P#7 You can make even formal CME work: JAMA 1999; 282:867-874) Interactivity: Q&A, case discussion, reflection, MCQs, audience response systems, think-pair-share Sequencing: e.g. rounds

  21. P/P# 3,402: Use some kind of framework Improving performance: the Pathman-PROCEED model Davis et al, BMJ, 2003

  22. Framing the talk… • Variation in practice: the clinical care gap from national and local levels • What causes the variation? • With this framework, what have we learned about effective (and maybe not effective) implementation strategies? • Are there forces driving these strategies? • So what? Implications for CPG

  23. IOM: “Redesigning CE in the Health Professions: a call for a CPD Institute” Macy-AAMC/AACN lifelong learning “Unmet Needs”: quality & safety Evidence-based medicine, guidelines Comparative effectiveness Health Professional Education Quality Chasm 1) Reports on healthcare 2011 2000

  24. Regulatory, Accreditation req’ts 2) Other forces… Evidence of effective education, QI, implementation methods The KT- PCORI implementation research agenda Continuum studies Outcomes (competency) –based education, Information explosion HIT, data feedback and reporting; transparency New diseases; prevention, screening QI initiatives, PI Bias, COI and Commercial support issues • Costs

  25. Framing the talk… • Variation in practice: the clinical care gap from national and local levels • What causes the variation? • With this framework, what have we learned about effective (and maybe not effective) implementation strategies? • Are the forces driving these strategies? • So what? Implications for CPG implementation

  26. Implications for health systems Clinician issues: training in EBM, quality, health systems, implementation science Evidence, guideline: local adaptation, message alignment, metrics and tools Health system issues: alignment of clinical, quality, educational enterprises (EHR, policies) Educational delivery system: smart, effective, seamless, local education

  27. What’s AAMC doing in this space? One step at a time

  28. what’s AAMC doing in this space? Integrating quality • Integrating Quality • Reducing Variation • ae4Q- aligning & educating for quality: using quality data to drive educational interventions: rounds, M&M conference; rounds developed from quality measures, care gaps; team training; morbidity, mortality and improvement sessions • Teaching for Quality: a national faculty development initiative The clinical /health care enterprise: focus on quality metrics, patient satisfaction, costs The educational enterprise: focused on didactic courses and conferences, frequently (in CME) dependent on commercial interest, self-assessed needs

  29. More info: August 18-21, 2013 ddavis@aamc.org E-mail www.aamc.org/initiatives/cei www.g-i-n.net Web

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