Transcript Variation, CME and the path to better care

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
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Guideline developer
Methodologist
• How long in the
healthcare provider
guideline business?
Health administrator
Journalist
• Background
– MD
Government policy maker
– PhD
Private policy maker
– RN
Consumer/patient
– Other health professional
advocate
– Administrator
Professional society
– Policy expert
member
– other
Educator
HIT Specialist
Information
Specialist/Librarian
The clinical care gap
Ideal, evidence-based
practice
clinical care gap
clinical care gap
Current practice
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?
The evidence-to-practice puzzle
What causes the gap?
The evidence-to-practice puzzle
Sue: the KU experience
Or: GO Jayhawks!!
The University of Kansas
Experience
Interprofessional, Multidisciplinary, Multi-faceted
Team Approach
18
Effectiveness of CME, Chest. 2009;
135 (3) (suppl) 49S-55S.
Pathman Matrix of Methods to Change Provider Performance
Methods/
Stages
Predisposing
Enabling
Reinforcing
Awareness
Agreement
VTE Prophylaxis
PICC catheter,
Cases at Patient
safety conference
Podcasts, Signs
on unit, Buttons,
webinars
Resident
compliance
training,
My KU VTE
orientation,
prophylaxis,
Departmental
Small groups:
Trauma, Gen
Surgery, ENT,
Urology, CTS,
Oncology, ObGyn, IM
Adoption
Adherence
Nursing Unit
Education,
Patient Education
Algorithms
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”
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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 patienteducation, 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
• training required:
demonstrate moderate
one part clinical, one
effectiveness (ES: 5part educational
15%)
• toolkit useful,
• OLs= educational
adapted for use in a
influentials=
particular community
community-identified
or work setting
respected clinicians
• OLs work within the
community to effect
change
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
Predisposing
Enabling
Reinforcing
Awareness
Agreement
Adoption
Adherence
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
[email protected]
Dave Davis, AAMC
[email protected]