Implementing Guidelines E-GAPPS Workshop

1. Implementing GuidelinesE-GAPPS Workshop Sue Pingleton, University of Kansas Dave Davis, AAMC and University of Toronto

2. 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

3. 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

5. The clinical care gap Ideal, evidence-based practice clinical care gap clinical care gap Current practice

6. Examples of the clinical care gap

7. And in Canada, too

9. The Evidence…. Chest, 2012;141 (2) (Suppl):53S-70S

10. The Clinical Gap… Venous Thromboembolism (VTE) - University of Kansas Hospital

12. What causes the gap? • Interactive large-group exercise

13. What causes the gap?The evidence-to-practice puzzle The clinician The evidence/guideline The educational delivery system • Health Care • System issues • Patient • Team members

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

15. Sue: the KU experience Or: GO Jayhawks!!

16. The University of Kansas Experience

17. Interprofessional, Multidisciplinary, Multi-faceted Team Approach

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

20. Awareness Methods/ Stages Agreement Adoption Adherence Predisposing VTE Prophylaxis PICC catheter, Cases at Patient safety conference Podcasts, Signs on unit, Buttons, webinars Resident compliance training, orientation, My KU VTE prophylaxis, Departmental Small groups: Trauma, Gen Surgery, ENT, Urology, CTS, Oncology, Ob-Gyn, IM Nursing Unit Education, Patient Education Algorithms Enabling Reminders, Audit/ feedback, other tools Reinforcing SYSTEMS: Standard Orders Best Practice Alert’s Pathman Matrix of Methods to Change Provider Performance

22. Results…Sustained Improvement

24. Formal CME Lectures, workshops, small groups Informal education; peer consultation Academic Detailing Print, AV Reminders; audit/feedback Opinion Leaders Patient Strategies Other Strategies and a framework An educational toolkit

25. 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 1) Formal “CME”

26. What do you think about these new guidelines, anyway? Informal; hallway, phone consults Formal consults; letters, etc Outreach visits, like ‘academic detailing’ 2) Mentoring/peer consultation

27. 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

28. includes mailed, unsolicited materials little/no evidence that such measures, alone, change performance or HC outcomes May predispose to chanfe 4) Print, AV, on-line Materials

29. 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 5) Reminders; audit and feedback

30. 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 7) Patient Strategies

31. 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 8) Opinion Leaders

32. 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

33. …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

34. Other strategies?

35. 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…..

36. the Pathman-PROCEED model National Local

37. 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

38. Implementing GuidelinesE-GAPPS Workshopfurther information Sue Pingleton, University of Kansas spinglet@kumc.org Dave Davis, AAMC ddavis@aamc.org