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CPI 01-141 – HSR Study

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
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.

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.

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.

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.

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 Project

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Journal Articles

  1. BootsMiller BJ, Yankey JW, Flach SD, Ward MM, Vaughn TE, Welke KF, Doebbeling BN. Classifying the effectiveness of Veterans Affairs guideline implementation approaches. American journal of medical quality : the official journal of the American College of Medical Quality. 2004 Nov 1; 19(6):248-54. [view]
  2. Schneider JE, Peterson NA, Vaughn TE, Mooss EN, Doebbeling BN. Clinical practice guidelines and organizational adaptation: a framework for analyzing economic effects. International journal of technology assessment in health care. 2006 Jan 1; 22(1):58-66. [view]
  3. Flach SD, McCoy KD, Vaughn TE, Ward MM, Bootsmiller BJ, Doebbeling BN. Does patient-centered care improve provision of preventive services? Journal of general internal medicine. 2004 Oct 1; 19(10):1019-26. [view]
  4. Ward MM, Doebbeling BN, Vaughn TE, Uden-Holman T, Clarke WR, Woolson RF, Letuchy E, Branch LG, Perlin J. Effectiveness of a nationally implemented smoking cessation guideline on provider and patient practices. Preventive medicine. 2003 Mar 1; 36(3):265-71. [view]
  5. Doebbeling BN, Vaughn TE, McCoy KD, Glassman P. Informatics Implementation in the Veterans Health Administration (VHA) Healthcare System to Improve Quality of Care. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium. 2006 Oct 1; 204-8. [view]
  6. Ward MM, Yankey JW, Vaughn TE, BootsMiller BJ, Flach SD, Welke KF, Pendergast JF, Perlin J, Doebbeling BN. Physician process and patient outcome measures for diabetes care: relationships to organizational characteristics. Medical care. 2004 Sep 1; 42(9):840-50. [view]
  7. Doebbeling BN, Chou AF, Tierney WM. Priorities and strategies for the implementation of integrated informatics and communications technology to improve evidence-based practice. Journal of general internal medicine. 2006 Feb 1; 21 Suppl 2:S50-7. [view]
  8. Ward MM, Yankey JW, Vaughn TE, BootsMiller BJ, Flach SD, Watrin S, Doebbeling BN. Provider adherence to COPD guidelines: relationship to organizational factors. Journal of evaluation in clinical practice. 2005 Aug 1; 11(4):379-87. [view]
  9. Lyons SS, Tripp-Reimer T, Sorofman BA, Dewitt JE, Bootsmiller BJ, Vaughn TE, Doebbeling BN. VA QUERI informatics paper: information technology for clinical guideline implementation: perceptions of multidisciplinary stakeholders. Journal of the American Medical Informatics Association : JAMIA. 2005 Jan 1; 12(1):64-71. [view]
  10. Fung CH, Woods JN, Asch SM, Glassman P, Doebbeling BN. Variation in implementation and use of computerized clinical reminders in an integrated healthcare system. The American journal of managed care. 2004 Nov 1; 10(11 Pt 2):878-85. [view]
  11. Welke KF, BootsMiller BJ, McCoy KD, Vaughn TE, Ward MM, Flach SD, Peloso PM, Sorofman BA, Tripp-Reimer T, Doebbeling BN. What factors influence provider knowledge of a congestive heart failure guideline in a national health care system? American journal of medical quality : the official journal of the American College of Medical Quality. 2003 May 1; 18(3):122-7. [view]
Conference Presentations

  1. Doebbeling BN, Flanagan M. Facility and Provider-level Determinants of Depression Screen Adherence. Paper presented at: VA HSR&D National Meeting; 2006 Feb 16; Arlington, VA. [view]
  2. Fung CH, Woods JN, Asch SM, Glassman P, Doebbeling BN. Variation in Implementation of Computerized Clinical Reminders in the VHA. Paper presented at: VA HSR&D National Meeting; 2004 Mar 10; Washington, DC. [view]
  3. Fung C, Woods JN, Asch S, Doebbeling BN. Variation In The Use Of Computerized Clinical Reminders In An Integrated National Delivery System. Paper presented at: Society of General Internal Medicine Annual Meeting; 2004 May 14; Chicago, IL. [view]

DRA: Health Systems
DRE: none
Keywords: Clinical practice guidelines, Organizational issues
MeSH Terms: none

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