Guideline “Implementability” Appraisal or if you write it will they use it?

1. Guideline “Implementability” Appraisal or if you write it will they use it? Jean Slutsky Director, Center for Outcomes and Evidence September 4, 2008

2. Overview • Definitions • Pitfalls • Solutions • Resources

3. Design and deployment of systems, tools, and strategies designed to influence clinicians’ behavior toward adherence to guideline recommendations Measurement: changes in the structure, process, and outcomes of care Source: Rick Shiffman Characteristics that predict the relative ease of implementation of guideline knowledge Measurement: ease of accuracy of transformation of recommendations of systems, tools, and strategies that influence care; prediction of barriers Implementation vs. Implementability

4. Precision • The tension exists in the uncertainty that resides in the swampland known as the evidence gap and the need to be exact to assist implementation

5. How do guideline developers deal with uncertainty? • They unintentionally (or intentionally?) make recommendations that are vague or imprecise • Periodicity “as needed” “routinely” “as indicated” • Importance “as appropriate”

6. The consequences of imprecision • It leads to variability because everyone decides what “as needed” means • Hard to develop organizational systems to enhance guideline use when statements are hard to interpret • It yields the authority of the guideline panel to the individual implementer

9. The Guideline Implementability Appraisal (GLIA) The objective of GLIA is to provide a tool for the appraisal of the implementability of clinical guidelines. • Global • Precisely under what conditions to do something • Decidability • Precisely under what conditions to do something

10. The Guideline Implementability Appraisal (GLIA) • Executability • Exactly what to do under the circumstances defined • Effect On Process Of Care • Degree to which the recommendation impacts upon the usual workflow of a care setting • Presentation & Formatting • Degree to which the recommendation is easily recognizable and succinct

11. The Guideline Implementability Appraisal (GLIA) • Measurable Outcomes • Degree to which the guideline identifies markers or endpoints to track the effects of implementation of this recommendation • Apparent Validity • Degree to which the recommendation reflects the intent of the developer and the strength of the evidence

12. The Guideline Implementability Appraisal (GLIA) • Novelty/Innovation • Degree to which the recommendation proposes behaviors considered unconventional by clinicians or patients

13. The Guideline Implementability Appraisal (GLIA) • Flexibility • Degree to which a recommendation permits interpretation and allows for alternatives in its execution • Computability • Ease with which a recommendation can be operationalized in an electronic information system BMC Medical Informatics and Decision Making 2005, 5:23 http://gem.med.yale.edu/glia/login.htm

14. Resources • http://gem.med.yale.edu/cogs/links.do • http://gem.med.yale.edu/glia/login.htm • http://gem.med.yale.edu/default.htm • www.guideline.gov • www.g-i-n.net