Embed Evidence-Based Guidelines into Daily Clinical Practice

Improving Chronic Care: Decision Support
  1. Identify existing guidelines.
  2. Review guidelines and select the best one(s) for your clinical setting. Make sure they are based on the best medical evidence.
  3. Teach providers the basics of evidence-based medicine and guideline review.
  4. Have providers review and discuss guidelines to develop consensus.
  5. Customize guidelines for your organization, within the boundaries of the evidence.
  6. Use a standardized assessment to diagnose and determine disease control and risk for complications (heart, eyes, kidneys, etc.) to guide management for all patients.
  7. Consider conduction a baseline chart audit to benchmark your current practice against agreed upon guidelines. 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. 
  8. Use flowsheets, pathways, or checklists to embed guidelines into daily practice.  The guidelines include triggers for care.
  9. Link guidelines to the information system to provide prompts.
  10. Review and update guidelines for care regularly (at least yearly).
  11. Remove barriers identified with previous guidelines.

 

Tips

  • Don't reinvent the wheel! Obtain existing guidelines from the National Guideline Clearinghouse or use standards from reputable organizations.
  • Involve a provider champion or your Medical Director in selecting guidelines, but be certain to obtain consensus on guidelines among the providers you expect to implement them. Focus initial effort on guidelines that are easily agreed upon. Don't get sidetracked by controversial topics: work on those guidelines later.
  • Mix and match guidelines as needed. 
  • Set clear expectations and timelines for guideline development, review, and adoption.
  • If committee review is required for accepting a guideline, have the committee consider only the evidence-based guideline.
  • Include evidence summaries that accompany good guidelines to facilitate discussions.
  • Send a physician to a certified medical education (CME) session on evidence-based medicine.
  • To get buy-in from influential naysayers, involve them in the process.
  • Remove barriers to guideline implementation, such as unavailability of needed vaccines, slow turnaround time for lab results, inertia.
  • Don't get mired down in complex algorithms or standards of care.
  • Talk to other organizations that have already customized guidelines to get the fastest process in place.
  • 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. Try a "lunch and learn" session to achieve this.
  • Try to integrate the chart audit with development of the registry. Talk to other organizations that have already customized guidelines.
  • The patient encounter form may also be know as a visit note, flowsheet, treatment planning form, order entry form, etc.
  • Make it as hard as possible to ignore the guideline. Make it easier to do the right thing (e.g., check a box instead of having to write out a lot of information).
  • Make it efficient to follow guidelines. Physicians will be more likely to use them if they save time.
  • Make it hard to forget to follow guidelines: work with the lab to develop staged testing protocols (e.g., automatic microalbumin measurement when an annual screening U/A is negative for protein to avoid recall of patient/resubmission of urine).
  • Ask teams that are already practicing evidence-based medicine to spread the word. If a team is not practicing this way, have them visit another clinic that is.
  • Think about why guideline implementation is not working:
    • Lack of awareness
    • Lack of agreement
    • 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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