overview on cpg implementation
TRANSCRIPT
Overview on CPG Implementation
(CPGI)By
Dr. Yasser Sami A. AmerMBBCh, MS Pedia., MS HCI, CPHQ, FISQUA
CPG Methodologist, CPG Steering Committee, CPG Unit, Quality Management Department, King Saud University Medical City
CPG Adaptation Workshop, INA Santé, Tunisia, 24-26 May 2016
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CPGI“The concrete activities and interventions undertaken to turn policies into desired results“
Guidelines for clinical practice: from development to use. IOM, 1992
CPGs Practice
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CPG “Implementability”Set of characteristics that PREDICT the relative ease of implementation of CPG recommendations.
Implementability…….BEFORE implementation
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How to Measure Implementability?
Ease and accuracy of translation of guideline advice into systems that influence care.
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Dissemination & ImplementationNothing could be more frustrating than
producing a CPG that is then ignored by not being disseminated nor implemented
nor updated.
The concept of the ‘LIVING’ CPG
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:: Evidence to practice/ knowledge to action cycle ::
CPG Implementation (CPGI)Strategies & Tools
CPGI Tools
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Adapt/ design CPGI Tools to be made available at the point of care (* MR/ EMR)
Examples• Clinical Algorithms• Integrated Care/ Clinical Pathways• Protocols• Policies & Procedures• Chart Documentation/ forms (e.g. Physician Order Sets:
paper vs. CPOE system +/- CDSS)• Quick Reference Guides/ Physician Guides & Pocket
Guide/Reference Cards (at-a-glance summary of key recommendations).
• Mobile Apps
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• Clinical audit criteria (tool)
• Quality/ Performance measures (process, outcome KPIs)
• Quality Tools (e.g. FMEA)
• Slide Presentation.• Wall Poster.• Patient Resources/ Information (HE guides).• Foreign language Translation (Non-Arabic, Non-French).• Implementation Tool Kits (collections of tools and/or strategies).• Staff Training/ Competency Material.
CPGI tools (cont’d)
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With or without Clinical Decision Support (CDS)
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Mobile Apps (mHealth)
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NICE Guidance‘Tools and resources’
• Baseline assessment• Clinical audit• E-learning module• Slide set• Tailored education
support • Case scenario• Commissioning guide• Costing statement
• shared learning• ‘Do not do’
recommendations• Research
recommendations• Guidance into
practice
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CPG implementation strategies/ interventions
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I - Professional interventions• Identify barriers & facilitators to CPG implementation/ knowledge use• Distribute and advertise (CPG educational material)• Present CPG materials at meetings• Local consensus process that CPG should be implemented• Educational meetings (lectures, conferences, workshops, or CME/ CPD)• Educational outreach visits• Local opinion leaders (Clinical/ quality champions)• Patient-mediated interventions • Audit and feedback• Reminders (manual or computerized)• Marketing • Others (?) Gagliardi A et al
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II - Organizational interventions(3 categories)
(i) HCP-oriented interventions:-• Revision of professional roles or teams (aka. Professional substitution, boundary
encroachment)• Leadership engagement• Create a Clinical implementation/ multidisciplinary team• Formal integration of services (aka. Seamless/ continuity of care)• Skill mix changes• Improve satisfaction of healthcare providers (non-financial)• Communication and case discussion between distant healthcare providers• Others(?)
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Organizational interventions (cont’d)
(ii) Patient-oriented interventions:-• Mail order pharmacies (e.g. compared to traditional pharmacies).• Presence and functioning of adequate mechanisms for dealing with patients'
feedback, suggestions and complaints• Consumer participation in governance of healthcare organization• HE activities• mass media campaign• Others (?)
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Organizational interventions(iii) Structural interventions:-• Changes in the setting/site of service delivery • Changes in physical structure, facilities and equipment• Changes in MR systems (HIT)• Changes in scope and nature of benefits and services (method of service delivery)• Presence and organization of quality monitoring mechanisms/ Change in Quality
improvement or Performance Measurement systems• Ownership, accreditation, and affiliation status of hospitals and other facilities • Staff organization • Others(?)
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CPG implementation strategies
Dissemination Process (print/ e-/website)Local Clinical Champions.Awareness raising/ training activities.Networking and linking with existing projects
(e.g. CPD/CME activities, Accreditation, etc..).Patients as champions for change.Regular M & E (The ‘living’ CPG concept!).
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“Multi-faceted” are more effective than single strategies in CPGI!
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Facilitators and Barriers in CPGI
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Facilitators of CPGIDomain
Positive attitudeLearning through small group interaction
Individual
Leadership supportChampionsTeam work collaboration
Organizational
Scientific specialized association supportInter-organizational collaboration
networks
Environmental
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CPG Implementation Failure! BARRIERS!Extrinsic to CPG:provider & care system-related
Intrinsic to CPG: (>Methodology!)ambiguity – inconsistency - incompleteness
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FMEA RESULTS – Major Failure ModesIdentified potential failure modes in CPGs implementation with the highest RPN (≥ 80):-1. Auditing of the CPGs (e.g. data management process).2. Adaptation process (e.g. AGREE appraisal, Ext. review).3. Networking with existing projects.4. Awareness/training activities.5. Accessible printed & electronic implementation tools6. Advocates from clinical/ quality champions
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RESULTS - Actions taken
1. Auditing: Supported by Pedia. CGC, DQT & QMD as a part of Quality sustainability plan and CPG Program.
2. Adaptation: (e.g. AGREE: 4 appraisers, Review: all Stakeholders)3. Networking: (e.g. Dept. QIP, CPD, Accreditation, Research)4. Awareness/ training activities: Organized regularly.5. Printed & electronic copies*: Available and accessible to HC
providers at points of care. *eSiHi!6. Champions: Consultants/ senior practitioners encouraged to get
involved in CPG adaptation/ implementation.
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CPG Implementation cycle
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CPG Implementation cycleFinal
CPG
Approved + CPGI Tools + Plan
For
mulate I
mplementation multidisciplinary team
Baseline (Pre-) Audit
of current CP
Pilot I
mplementation Identify
barriers
Prioritize dissemination strategies and start
Prioritize 1 – 3 key
Rs to i
mplement
Prioritize i
mplementation strategies
Post-implementation M & E
Regular checkpoints
(PIPOH-KPI)
Regular review & update of published evidence
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Effectiveness of CPGs implementation interventions
Slide courtesy of Dr. Ulfat Shaikh
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G-I-N Working Groups (IWG, PMWG)
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What is your role as a HCP in CPGs? “spread the word”
1) CPG implementers/users:“Your continuous feedback!”
2) CPG developers/adapters.3) Improvement research projects.
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CPGI• Start with prioritized with strong evidence• Used a planned and structured approach• Identify key stakeholders• Understand facilitators and barriers• Use evidence-based implementation interventions• Monitor and evaluate effectiveness• Modify and improve your approaches•PLAN – DO – STUDY – ACT – ENJOY!
Slide courtesy of Dr. Catherine Marshall
CPGs & HTAsidentifying similarities & differences
A collaborative discussion session
ByDr. Yasser S. Amer on behalf of, King Saud University, CEBHC-KT, CPG
Program Expert Panel
CPG Adaptation Workshop, INA Sante, Tunisia24-26 May 2016
Definitions• Healthcare technology is defined as prevention and
rehabilitation, vaccines, pharmaceuticals and devices, medical and surgical procedures, and the systems within which health is protected and maintained.
• Technology assessment in health care is a multidisciplinary field of policy analysis. It studies the medical, social, ethical, and economic implications of development, diffusion, and use of health technology.
Reference: International Network of Agencies for HTA (INAHTA) website http://www.inahta.org/hta-tools-resources/
Note: A Memorandum of Understanding between INAHTA and G-I-N has been signed at the INAHTA Annual Meeting in 2009.
HTA“The systematic evaluation of properties, effects, and/or
impacts of health care technology. It may address the direct, intended consequences of technologies as well as their indirect, unintended consequences. Its main purpose is to inform technology-related policymaking in health care. HTA is conducted by interdisciplinary groups using explicit analytical frameworks drawing from a variety of methods." Goodman, Clifford S. HTA 101: Introduction to Health Technology Assessment, January 2004.https://www.nlm.nih.gov/hsrinfo/evidence_based_practice.html
• CPGs & HTAs together, builds a body of best practice initiatives. Evidence of the effectiveness of health technology is only one part of the picture.
• Support evidence-based decision making by collecting and analyzing [E] from research in a systematic and reproducible way and make it accessible/ usable for decision-making purposes
Both CPGs & HTAs . . . .
Why CPGs & HTA? Similarities
•Same objectives – to inform policies and practices
•Same EB approach and methodologies – systematic reviews and economic evaluations
•Achieving more with limited resources•Prioritized health topics can be shared
Links?• Although, CPGs & HTAs are two standalone tools to support
evidence-based healthcare; Several links between them may exist including:-
• Identification of high priority health topics for synthesis; topics that have been already prioritized for CPGs’ development or adaptation can be used to inform and prioritize topics for HTAs
• HTAs can further support an evidence-informed decision by policy-makers whether to incorporate a new HT (e.g. pharmaceutical, device,..etc.) in the HC system. A good example is chemotherapeutic agents in LMICs.
CPGs versus HTAs: differences HTAs CPGs
Policy/ HC system level (decision support)
Clinical practice & patient level (decision support)
Judgements about the extent to which these “recommended” interventions should be available in a specific HC system are left to health policymakers.
Recommendations from EBCPGs, are considered the most effective management of a specific condition. They mainly include benefits and harms of the interventions.
Reference: European Observatory on Health Systems and Policies-HTA Policy Brief 2005
Conclusion• HTA and CPG development share objectives and methodologies
• Upstream HTA can inform downstream CPG development
• CPGs can also inform HTA
Slide courtesy of MoH Singapore (G-I-N resources)
Questions for discussion• From your experience, what are the most important factors
that facilitate CPGs implementation?• What are the main barriers against successful and
sustainable CPGs implementation?• Should HTA agencies (or projects) link up with CPG
agencies (or projects) ? Should these linkages be national or international?
• Should HTA development/ adaptation be an integral part of the CPGs development/ adaptation projects?
• Others………………………………..?
