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CPI 01-141
Determinants of Clinical Guideline Implementation Effectiveness
Bradley N. Doebbeling, MD MSc Iowa City VA Health Care System, Iowa City, IA Iowa City, IA Funding Period: October 2001 - September 2003 Portfolio Assignment: Health Care Organization and Implementation |
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BACKGROUND/RATIONALE:
Despite growing numbers of available clinical practice guidelines (CPG), there has been little systematic investigation concerning effective mechanisms to implement the CPGs into practice. Our research investigates the relationship between VA facilities’ organizational characteristics, implementation structures and processes, and effective CPG implementation. OBJECTIVE(S): The specific aims are to: 1) Describe rates of adherence with current CPGs in acute care facilities; 2) Identify factors (organizational structures, implementation approaches, etc.) associated with effective dissemination of, and adherence with CPGs; 3) Develop and validate predictive models of the relationships between organizational characteristics, CPG characteristics, and CPG implementation processes, with outcomes, especially provider adherence. METHODS: This multi-method, quasi-experimental study utilizes qualitative and quantitative methods. National patient survey and chart audit performance data assessed consistency of ranking in adherence across multiple CPGs. Selected VAMCs represented a range of VISN adherence, geographic, bed-size, teaching affiliation, patient gender and ethnic distributions. Fifty focus groups (16 physician, 17 administrator and 17 other clinician groups, N= 322) were conducted in 19 VAMCs to identify important organizational barriers and facilitators to implementation. A system-wide Quality Manager (QM) survey examined organizational context, dissemination mechanisms, monitoring, feedback, provider knowledge, attitudes and adherence. Data analyses led to development of a survey to assess provider-level factors influencing CPG adoption and adherence. A provider survey of 1,782 physicians, 818 physician assistants/nurse practitioners, and 1,655 nurses, that assessed provider-level factors influencing CPG adoption and adherence, is complete. Structured interviews with hospital directors and Chiefs of Staff are currently being conducted and transcribed for qualitative data analysis. FINDINGS/RESULTS: We developed and compared alternate methodologies for benchmarking institutional performance across multiple performance measures. Physicians, clinicians, and administrators varied with regards to their attitudes and perceptions of barriers and facilitators to CPG implementation. Analyses indicate that guidelines must fit into contemporary practice. Technologic and human resources, reminder automation and documentation are required. Accountability contributes to guideline implementation within a facility. The QM survey (N = 126 facilities, 91%), and the provider survey (N=2438, 58%) demonstrated wide variation in timing and approaches to implementation, organizational context, and guideline specific factors. Analyses have identified organizational factors predicting successful implementation of and adherence to CPGs. For example, cooperative culture and support, and the presence of a structured implementation plan predicted adherence to the diabetes performance measures. VISN influence, cooperation between physicians and senior administrators and deadlines, participation, and timing were also found to be possible predictors of adherence. Strong evidence was found for the importance of mission, capacity, professionalism and patient population characteristics that influence CPG adherence. However, other analyses found that VA facilities with disadvantaged patient populations appear just as likely to have fully implemented clinical effectiveness programs, thus, suggesting that research should focus on the importance of provider and other organizational factors. In addition to a need for improved organizational systems for CPG implementation, recent analyses have found that a fit between the CPG and provider values makes a difference. Provider values and attitudes toward a CPG impact the extent to which organizational systems intend to improve adherence. In the final phase of the study, 13 hospital directors, and 6 chiefs of staff were interviewed to identify the steps in the implementation process. IMPACT: Institutional and system-level organizational factors, guideline and implementation-process factors, and individual provider-level factors all appear to be important in facilitating effective clinical practice guideline implementation. In a series of manuscripts either in development or submitted, we have identified effective approaches to CPG implementation. Further research and translation will need to incorporate these findings into practice, which should lead to improved healthcare for veterans. External Links for this ProjectDimensions for VA Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects. Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Health Systems Science
DRE: none Keywords: Clinical practice guidelines, Organizational issues MeSH Terms: none |
