iom workshop on standards for clinical practice guidelines january 11, 2010 presentation to...
TRANSCRIPT
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IOM Workshop on Standards for Clinical Practice Guidelines
January 11, 2010Presentation to Committee on Standards for
Developing Trustworthy CPGs
Karen KellyThomas, PhD, RN, FAANCEO
National Association of Pediatric Nurse Practitioners (NAPNAP)
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Scope of presentation/perspective
NAPNAP Healthy Eating and Activity Together (HEATsm) Program and CPG
NAPNAP Keep Yourself/Your Children Safe and Secure (KYSS sm) Program and outcomes
AWHONN RBP Program and projects1996-2003Reference List for 4 projects
Research and Development in 4 hospitals1975-1996
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Bernadette Melnyk, PhD, RN, CPNP/NPP - ASUEvidence-based Practice in Nursing and Healthcare
Melnyk et al Seven Steps Step 0 - Cultivate a spirit of inquiry Step 1 - Ask clinical question in PICOT format (population, area
of interest, comparison intervention or group, outcome, time) Step 2 - Search for the best evidence Step 3 - Critically appraise the evidence Step 4 – Integrate the evidence with clinical expertise and
patient preferences and values Step 5 – Evaluate the outcomes of the practice decisions or
changes based on evidence Step 6 – Disseminate the result
Other models in use i.e. Titler/Iowa; Stevens/UTHSA
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The biggest challenges facing developers today
Confessions of a contingency theory based and pragmatic CEO
Finding right people, time and money; learning up Determining clinical discipline and practice specificity Deciding to develop, adopt, endorse, adapt or not Developing trust, Recognizing competition and need for ownership Measuring uptake and claiming results of implementation Branding, creative packaging and access for clinician users Participating in the relentless quest for sustainability or
barbecuing a sacred cow Managing fear of the unknown and interfaces necessary
EHR, clinical decision support systems Translation of comparative effective research Developing CPGs that consider availability of health
information technology and payment modes
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Within our known healthcare universe, environment, systems, and contexts within
Looming EHRs ‘meaningfully used’ Principles of transparency Knowledge of performance measures Knowledge of gaps and limitations Political, science and human communities The activities as forethought Within knowledge that stopping is harder than
starting Within core of truth of best practice universe
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Yet knowing life feels more like a gyroscope teetering toward more knowledge and stronger trust
Never trust the teller. Trust the tale. (D.H. Lawrence)
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What do we do when scientific evidence is absent or poor?
Admit it and move ahead
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Reconciling Differences
Agree with Pawlson (2009) definition: CPGs are evidence based statements of optimal (‘best’) practices
Value IOM (1990) definition: Clinical practice guidelines are systematically developed statements to assist the practitioner and patient decisions about appropriate health care for specific clinical circumstances
Use a systematic process Empower science teams to decide Trust spirit of volunteer commitment Trust clinical judgment of expert and experienced
clinicians (and intuition…with recognition)
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Reconciling disagreements
Select a schema to appraise evidence quality and stick to it
Avoid every impulse to create another schema or scoring method (82+ is enough!)
Encourage lusty debate that informs all team members and others
I think we may safely trust a good deal more than we do
(Emerson)
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How we accommodate guidelines to subgroups whose treatment outcomes may differ from ‘average’ patient
Pediatric population as primary group ‘Accommodation’ as standard in well child
visits, anticipatory guidance, and EPSDT Body of knowledge about children with special
healthcare needs AHRQ draft Core Set of Child Healthcare
Quality Measures for Medicaid and CHIP Programs – NAPNAP involvement and public comments (March1, 2010)
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Other important challenges Child-focused interdisciplinary guidelines that identify
contributions of different providers providing same care Recognition of child’s healthcare home and multiple
primary healthcare providers’ scope of practice Recognition of parent as primary health and care
provider Quest for integrated guidelines – provider inclusive
ASLAAAP/AAFPADAAnd who/how many others
CPGs that work in urban, suburban and rural settings Culturally appropriate CPGs
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NAPNAP recommendations for CPG Guideline Panel Membership
• Must be Provider inclusive • Balance membership of
diverse clinical expertsMethodologistsparent/consumers
Consider including an interpretive-hermeneutic researcher
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Managing ‘nattering nabobs of negativism’
Safire for Agnew
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Consider
Methods for selecting recommendations to apply CQI measures – identified as part of process, tag and prioritize, challenge the best testers with incentives, continuously define clinical effectiveness measures
Available rating/assessment tools – rank those available, recognize patterns, be pragmatic, polish the ‘tarnished silver’, don’t throw babe out with bathwater
Keep using the words credible and trust - it goes both and all ways
Development of economics of it all and true stakeholders of it all
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Administrative, accreditation, or legal approaches that might improve the quality of CPGs
Create and disseminate a briefing for stakeholder administrators that will inform
Promote AHRQ Guideline Clearing House If GLIA (Implementability Assessment) has validity and
reliability, push out to associations who develop guidelines with care to include developers of a few and developers of many of diverse healthcare providers
Disseminate AVUL (ambiguous, vague, underspecified language) as strategy for guideline developers
Reduce the size of the ‘black box’ of electronic guideline knowledge representation
Do not develop an accreditation process for a few; if developed process must be applicable to all developers
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Harmonizing and converging guidelines
Bring diverse groups together then send them out Expand opportunities for professional societies to develop
and become PBRNs as underframe Call the ‘best of the best’ to action Be careful what you ask for
Other characteristics of guideline standards that are important
I may not be perfect, but parts of me are excellent
(Ashleigh Brilliant, 1964)
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Promoting greater use of guidelines
Research utilization, knowledge utilization, evidence based practice (EBP research), research-based practice, translation research…and on
Use decades of acquired knowledge to create more champion opportunities for more developers to come together then push out
Go forth and disseminate Pay attention to the need for the proverbial resources Anyone using BridgeWiz (Shiffman, Nov 9, 2009 mtg
presentation)