What Good are Guidelines if Theyre Not Being Used

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What Good are Guidelines if Theyre Not Being
Used?

• Presented By
• Jay A. Krakovitz MD
• Board President - CCGC

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Colorado Clinical Guidelines Collaborative (CCGC)
A coalition of health plans, physicians,
hospitals, employers, government agencies,
quality improvement organizations and other
entities working together to implement systems
and processes, using evidence-based guidelines,
to improve healthcare in Colorado.
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What Does CCGC Do?

• Started 1996 to address inundation with multiple
  guidelines
• Develop ONE GUIDELINE per disease
• Best available evidence
• Consensus from 43 organizations
• Put systems in place to make sure the top 3-5 key
  issues per guideline get done

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SELECT - IDENTIFY
DEVELOP
REVISE
CCGC GUIDELINE PROCESS
FEEDBACK
DISSEMINATE
IMPLEMENT
MEASURE
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GUIDELINE DEVELOPMENT

• Guideline Committee
• Advisory Panel and Work Group
• Review Literature and current guidelines
• Use existing grading systems when needed
• Focus groups with PCPs
• Draft to board and membership for approval

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Current CCGC Guidelines

• Diabetes
• Depression
• Screening for Colorectal Cancer
• Asthma
• Pediatric and Adult Immunizations
• Upper Respiratory Infections
• Tobacco Cessation
• Cardiovascular Disease and Stroke (Obesity)
• Gestational DM

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CCGC Guidelines and Tools

• Long Version
• Short Version
• Chart Tracking Sheets
• Colored borders
• Punched holes
• Education Materials
• Patient
• Staff
• Physician

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CCGC Guideline Formats

• Hard copy
• paper
• laminated
• Web-based
• www.coloradoguidelines.org
• PDA

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Current Goals

• Reduce number of guidelines
• Provide reliable source for guidelines
• do research, gather experts and compile data
• Simplify the message
• One Page laminated quick reference to highlight
  key issues
• Provide tools
• Chart tracking forms help track patient data,
  education materials
• Promote consistency
• Same message to physicians, patients, health
  plans, employers

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GUIDELINE DISSEMINATION

• Mail to 10,000 physicians/providers
• Newsletters, articles, websites, email blasts,
  postcards, etc
• Lectures statewide
• Training Videos/CDs

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BUT

• GUIDELINES ALONE ARE NOT ENOUGH!

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The Problems

• Escalating Healthcare Costs
• Unaffordable for businesses and consumers
• Increased uninsured population ? increased costs
  (ER visits)
• Mediocre Quality
• IOM Quality Chasm Report
• RAND Study
• IOM Do No Harm Report
• Dissatisfaction with healthcare system
• Healthcare professionals on a treadmill
• Patients overwhelmed, distrustful, vulnerable
• Cottage Industry (silos)
• Lack of infrastructure and knowledge to implement
  change
• Reinvent wheel with each practice and each
  patient
• Behind in Technology
• Only 10-12 of practices on EMR
• Limited resources to purchase them

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A Systems Approach

• Healthcare has become very complex
• Need SYSTEMS and Systematic Approach
• Crossing the Quality Chasm
• When it comes to managing chronic illness (and
  preventive care), our current care systems cannot
  do the job. Trying harder will not work.
  Changing systems of care will.

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Need Widespread Collaboration to Accomplish This

• Colorado Trust grant
• Environmental scan - P4P, BTE, DOQ-IT,
  COHIE/CORHIO, etc. Perfect Storm
• CCGC Strategic Plan
• Performance Measures/Incentives
• Convene stakeholders to agree on COMMON measures,
  combine data, and use to provide feedback,
  incentives, designations
• Practice Redesign
• Consult with practices to help navigate the
  changing environment provide tools and teach
  effective models of care to help them redesign
  current systems
• Information Technology
• Catalyze existing activities to encourage IT
  adoption to build infrastructure, improve
  efficiency and care

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Improving Performance in Practice (IPIP)

• Background
• Colorado 1 of 2 states in country selected
• Initiated by ABMS, Boards and Societies for FP,
  IM, Peds
• Tie measures, practice redesign, collaborative
  networking to Board Cert
• Recruitment
• Year 1 16-20 practices for pilot
• Year 2 add 50
• Year 3 add 50-80 then spread throughout state
• Quality Improvement Coaches
• Practice Assessment (work flow, culture, QI, IT)
• Provide tools to make it easier for clinicians to
  provide the high quality care they want
• Registries, Lean Training, Planned Care Model
• Use collaborative networks to spread knowledge
  and change
• Identify and help overcome barriers
• Provide registries for data collection and
  measurement

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GUIDELINE IMPLEMENTATION

• IPIP is best vehicle to date to implement
  guidelines into practice
• Integrate guidelines/measures into daily
  routine
• Ideal scenario
• Embedded in computer
• Tie patient age, gender, history to guidelines
  for Preventive, Chronic, Acute Care

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GUIDELINE MEASUREMENT AND FEEDBACK

• When Performance Is Measured, Performance
  Improves. When Performance Is
  Measured and Reported,
  the Rate of Improvement
  Accelerates.
  (Thomas Monson, 1970)
• This principle applies to both patients and their
  providers
• DM Project examples
• Data
• Registries allow physicians to gather own data
• Also use HP data
• Common platform of measures ? Central Data
  Repository for comparison and meaningful feedback

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WHY MEASURES WHY DATA?

• If you dont measure it, you cant improve it.
  
• --Someone really smart

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5 STAGES OF DATA (GRIEF)

• Denial
• The data is wrong
• Anger
• Dont tell ME how to practice medicine
• Bargaining
• OK If I do this can I get paid more?
• Depression
• OY VEY
• Acceptance
• I had no idea.OK - lets get going!

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DATA PROVIDES OPPORTUNITIES

• If care is excellent opportunity to PROVE IT
• If not, opportunity to IMPROVE IT
• Collect and analyze own data
• Demonstrate quality of care
• Resolve disputes for P4P and Designation
• Compare self over time
• Compare self with peers

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SUSTAINING CHANGE

• In previous projects
• Practices told what to do.
• Changes made extinguished within minutes to hours
  after researchers left
• In new initiative
• Work WITH practices to learn together most
  efficient and effective ways to care for patients
  share with others
• Build infrastructure to incorporate ANY guideline
  or issue (even patient safety, risk management)
• Align incentives and change culture for
  sustainability

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GUIDELINE REVISION

• Work is NEVER DONE
• Still revising paper guidelines every 1-2 years
  until.embedded into computers

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BOTTOM LINE

• Healthcare has become very complex
• Could have BEST GUIDELINE in the worldbut if not
  being usedwhat good is it??
• Need to redesign our systems to integrate best
  practices (EBM) into daily routines
• Provide infrastructure (technology), practice
  redesign techniques and align incentives to make
  it easier to do the right thing!

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ULTIMATE GOALS

• Healthier Patients
• Happier Patients
• Happier Doctors and Staff

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Questions?
WEBSITE www.coloradoguidelines.org EMAIL
info_at_coloradoguidelines.org PHONE [phone]