7 critical steps to implementing clinical guidelines

Physician Executive, May-June, 2004 by Thomas J. Biuso

Guidelines are developed to fill the gaps between current knowledge and evidence as published in the medical literature, the Cochrane Database and actual physician practice.

Many physicians and physician executives believe that guidelines can effectively decrease clinical practice variation, improve clinical performance and favorably influence patient outcomes.

Evidence-based guidelines are decision support tools that facilitate the introduction of new knowledge into clinical practice. Standardizing them is absolutely essential. Guidelines do not implement themselves and they are often not used after dissemination. Implementation activities frequently produce only moderate acceptance.

Discussions about clinical guidelines should include:

* Physician attitudes about guidelines and strategies to promote their adoption

* Physician adherence to guidelines

* Standardized reporting

* Diffusion of information

* The role of guidelines in promoting quality medical care

Theoretically, practice guidelines come from sound clinical research. The guidelines are promulgated within health care systems and they, in turn, are used to generate quality indicators, performance measures in particular microenvironments, and outcomes data. (1)

One guideline, for example, recommends that all eligible patients receive a beta blocker after acute myocardial infarction. This recommendation translates into the quality indicator "prescription for beta blocker at discharge after MI."

The performance measure is the "percent of patients given a beta blocker after MI," and the outcome linked to this measure is the cardiovascular risk reduction in that group of patients compared to a control population.

Many variables

Despite the enormous work and energy invested in guideline authoring, the quality of individual guidelines varies considerably. That's why The Conference on Guideline Standardization issued a proposal in 2003 that presents a checklist for reporting guidelines. (2)

The checklist includes a description of the methods used to search the scientific literature, the criteria used to rate the quality of evidence (Figure 1), a description of the clinical condition and intervention that the guideline addresses, recommendations and rationale, and algorithm. Standardization of guidelines is critical to their acceptance and is necessary prior to the dissemination of such information.

Clinical guidelines may be successfully implemented in one location and not another. Dissemination of information is slow and acceptance suboptimal. The failure to use available scientific information is costly and potentially harmful. This promotes the continued overuse of unhelpful care and the underuse of effective care.

Donald Berwick states that several perceptions of an innovation determine its rate of spread. The perceived benefit of the change is the most powerful perception that leads to adoption. Second, the innovation must be compatible with the values and beliefs of the individual. The third factor affecting the rate of diffusion is the complexity of the proposed innovation.

Detailed and complex guidelines are less likely to be disseminated than simple ones. Trialability is another factor. That is, can the adopter find a way to test the change on a small scale without implementing it everywhere at first. Finally, operability is the last factor and it refers to the ease with which potential adopters can watch others try the change first. (3)

Barriers to change include:

* Lack of awareness or familiarity with the guidelines

* Inertia from previous practice patterns

* Inability to reconcile patient preferences with guideline recommendations

* Lack of adequate resources to permit adherence to the guidelines such as insufficient staff and increased practice costs (5)

These barriers are significant hurdles to overcome but with time, dedication, and a team approach the successful implementation of guidelines is achievable.

7 steps

In my roles as medical director in a health plan and my experience as a change agent for different medical staffs over the last several years, I identified seven key factors for the successful implementation of clinical care guidelines.

Execution of these steps requires true collaboration between the health plan and hospitals within its network. The combination of these factors has proven synergy and what emerges, in the long run, are aligned incentives between all parties.

1. Engineer physician leadership support for the project

The first order of business is to enlist the support of physician champions for the guidelines. Change occurs from within the health care system. The imposition of clinical guidelines by a managed care organization (MCO) never works. Rather, the medical director needs the support, expertise and momentum that physical leaders provide. These physicians are well-respected colleagues and they can ``tweak'' the guidelines to ensure that they are deliverable given local hospital and outpatient resources and physician practice patterns.

2. Align internal and external delivery incentives