Quality Management and Implementation of Best Practice Guidelines

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Quality Management and Implementation of Best
Practice Guidelines
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The Quality Improvement Model
QM means that system management is grounded in a
basic QI process the Shewart Cycle
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Quality Improvement and Processes

• Every process is perfectly designed to achieve
  the results it is producing
• Processes are the focus of quality efforts
• Complexity in processes typically arises from
  repeated efforts to improve a process without a
  systematic plan
• Types of complexity
• Mistakes and defects (reworkwork is repeated to
  correct for the errors of the past, whether they
  occur or not)
• Breakdowns and delays (work is held up due to
  lack of space, tools)
• Inefficiencies (how weve always done it.)
• Variations (extra steps to account for lack of
  uniformity)

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The First Imperative of QMAssuring Stable
Clinical Processes

• Process of care and practice guidelines
• Policies and procedures to assure processes
  operate as planned
• Performance standards/indicators and measurement
• Outcomes analyzed in light of performance of the
  process

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Outcomes and QM

• Outcomes focus on the so what? question
• Outcomes are the result (what has changed) of the
  activities
• For individuals and their families, what changed
  in their lives?
• For systems or communities, what changed for the
  population?
• Objectives versus outcomes
• Objective provide parenting skills classes for
  all parents with a newborn (this is
  measurabledid we reach all new parents?)
• Outcome parents demonstrate improvement in
  parenting skills, as measured by observed use of
  calming skills (also measurable... But harder to
  count and document)

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Putting QM, Outcomes and Practice Guidelines
Together
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Best Practice Clinical Processes
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Observations on Clinical Best Practice Guidelines

• Development of clinical practice guidelines
  should be linked to outcomes research,
  performance standards, and accreditation
• Research should examine successful implementation
  models
• Practitioners and consumers should be included in
  the development of practice guidelines
  
• Institute of medicine, 1990

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Best Practice Must Address Need for Cultural
Competence

• A culturally competent system of care values
  diversity, has the capacity for cultural
  self-assessment, is conscious of the dynamics
  inherent when cultures interact, has
  institutionalized cultural knowledge, and has
  developed adaptations to diversity
• Grace Wang,
• Association of Asian Pacific Community Health
  Organizations

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When Are Clinical Guidelines Justified?

• When they can be expected to increase
  significantly the value of clinical services by
  improving outcomes, increasing satisfaction or,
  lowering costs
• Lawrence Gottlieb, MD, MPP
• HMO Practice, March 1994

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Criteria for Development of Guidelines

• There is... Evidence that the medical or
  healthcare services under consideration can have
  a positive impact on a populations health in a
  cost-effective manner
• There is.....A gap between current medical
  practices or health programs and those proven to
  be (more) effective

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Criteria for Development of Guidelines

• It is...Apparent that closing the gap by shifting
  patterns of care of health programs towards some
  ideal will yield sufficient gains in terms of
  clinical outcomes, satisfaction, or costs, to
  justify the investment of resources required to
  close the gap
• And...The guideline implementation process must
  be carefully designed to address the major
  determinants of individual clinical practices as
  well as any process or systems barriers to change
• Lawrence Gottlieb, MD, MPP
• HMO Practice, March 1994

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Attributes of Good Guidelines

• The problem addressed by the guideline is clearly
  stated
• The method of development is clearly stated
• The population targeted by the guideline is
  clearly identified
• Exceptions to the guideline are clearly described
• The guideline is clearly presented and documented
• Handley and Stuart
• HMO Practice, March 1994

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The Context for Clinical Guidelines

• A clear understanding of the mission, vision and
  values of the organization are the foundation
• Good customer service is a given
• Some best practices will use more resources and
  others will use less than at present
• The process of guideline development includes
  ethical discussions
• the entire populations needs and those of
  individuals being served
• best practice direction and inclinations of
  individual practitioners

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Steps in the Process of Developing
Guidelines(Based on Handley and Stuart HMO
Practice, March 1994)

• Problem identification (identify gaps in each of
  outcome areas)
• Health status
• Patient satisfaction
• Provider satisfaction
• Cost/utilization
• Organizational impact
• Suitability screening
• See Gottliebs criteria above

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Steps in the Process of Developing Guidelines

• Data development
• Internal data (including current clinical
  outcomes, whether there is significant variation
  in care or outcomes, differences in
  cost/utilization related to variation, total
  cost of care for the population with current
  practice)
• Information from the literature
• Evidence grading ....All guidelines are based on
  evidence, somewhere between opinion (heavily
  influenced by anecdote and personal factors) and
  perfect scientific evidence (which doesnt
  exist). The classic evidence grading schemes are
  based on stratifying evidence by study design
  (Handley and Stuart)

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Steps in the Process of Developing Guidelines

• Evidence grading (in order of assumption
  regarding ability to predict outcomes)
• Randomized controlled trials
• Non-randomized concurrent cohort studies
• Non-randomized historical cohort studies
• Population based or case control studies
• Case series without control subjects
• Expert opinion
• (Handley and Stuart)

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Steps in the Process of Developing Guidelines

• Guideline development
• Set criteria for benefit
• Organize the literature and evidence grading
• Use the evidence to reassess whether guideline is
  justified
• Draft the guideline (see attributes above)
• Guideline formulation
• Review the gap between current and proposed
  practice
• Estimate the impact on outcomes
• Consider effects of changing variables on
  outcomes
• Articulate evaluation/measurement strategy and
  benchmarks

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Benchmarks for Performance

• A process to identify, examine, and evaluate best
  organizational practices from other organizations
  in order to improve the status and quality of
  your own organization
• The percentage of cases in which the objective is
  to be met and the time period within which this
  is to be accomplished (often derived from best
  practice site performance)

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Implementing Guidelines

• Train...Train...Train
• Measurement for performance on benchmarks
• Chart reviews for consistent application
• Analysis and trend charts to track progress over
  time
• Decision to keep, change, stop use of guideline
  should be based on data and updated review of
  research

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Implementing Guidelines

• Implementation is an ongoing process, not a one
  time event (see Shewart cycle)
• Assure existing guidelines are in stable use
  before adding new guidelines
• Limit number of new guidelines in any one year

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The Quality Improvement Model
QM means that system management is grounded in a
basic QI process the Shewart Cycle