Decision Support:
Embed Current Guidelines in the Care Delivery System
- Identify current guidelines for the treatment of HIV/AIDS disease and co-morbid conditions. Note clinical settings in which exceptions to guideline recommendations may be appropriate. Consider amending the guidelines to include these exceptions.
- Establish screening alerts for specific patient needs, such as adherence training and secondary prevention tests.
- Review guidelines and select the best one(s) for your clinical setting. Make sure they are current.
- Teach providers the basics of evidence-based medicine and guideline review.
- Have providers review and discuss guidelines to develop consensus. Decide which staff members are responsible for implementing specific items in the guidelines.
- Consider use of specialized software to "couple" guidelines with clinical care decisions.
- Customize guidelines for the clinic, within the boundaries of the evidence.
- Consider conducting a baseline chart audit to benchmark your current practice against agreed-upon guidelines.
- Use flow sheets, pathways, or checklists to embed guidelines into daily practice and into the registry system. The guidelines include triggers for care. Print out flow sheets prior to each visit. During the visit, incorporate the plan for the next visit on the flow sheet.
- Review and update guidelines for care routinely (quarterly is suggested).
- Remove barriers identified with previous guidelines.
- To save time and energy, obtain existing guidelines from the US Department of Health and Human Services (DHHS).
- Involve a provider champion or your medical director in selecting and adapting guidelines, but be certain to obtain consensus on guidelines among the providers who will implement them.
- Focus initial effort on guidelines that are easily agreed upon. Don’t be sidetracked by controversial topics — work on those guidelines later.
- Mix and match guidelines as needed.
- Monitor practice patterns and appropriateness of both rules and exceptions to guidelines.
- Set clear expectations and timelines for guideline adaptation, review, and adoption.
- Include evidence summaries that accompany good guidelines to facilitate discussion.
- Consensus building is not perfection. It is about compromise and a willingness to "try." Therefore, discussion, negotiation, and prioritizing will be important.
- Send a physician to a Continuing Medical Education course on evidence-based medicine.
- To get influential naysayers to "buy in" to following guidelines, involve them in the process of selecting and adapting the guidelines.
- Don’t get mired down in complex algorithms or standards of care.
- Keep chart abstraction simple and quick: collect only the data that are needed.
- Have providers abstract a random sample of their own charts. This helps them discover the gap between what they know is good practice and what they actually do. (Note: This is a very important process and should not be skipped. Maybe have a "lunch and learn" session to implement this.
- Try to integrate the chart audit with development of the registry. Talk to other clinics that have already customized guidelines to get the fastest process in place.
- Agree before the audit which patients to include (see Clinical Information System for establishing a registry). Do NOT omit charts because a randomly selected chart is not that of a "typical" patient. Often, unintended consequences can be good learning experiences for the entire team.
- Make it difficult to ignore the guideline.
- Include non-clinical information (e.g., social situation, data on funding source) that affects care or billing. Also include triggers for non-core measures (e.g., annual physical examination, rectal examination, HPV screening, nutrition assessment).
- Try different ways of inserting the flow sheet into the patient record. Try to incorporate as much data as possible on a single form.
- If a team is already practicing evidence-based medicine, use the team members to spread the word. If a team is not practicing this way, have them visit another clinic that is.
- Monitor the efficiency of encounters and the incidence of missed clinical tasks.
- Survey provider stress level regarding clinical encounters.
- Incorporate review and update of guidelines into the job description of the physician champion or other appropriate staff member. Think about why guideline implementation is not working:
- Lack of awareness
- Lack of agreement
- Self-efficacy
- Outcome expectancy
- External factors (time, money, resource availability)
- Inertia
- Discuss which of these factors is playing a role. You may have to address multiple issues simultaneously.
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