9 Best Practices for Implementing Evidence-Based Guidelines

Hospital leaders agree: Evidence-based care protocols to guide how care is delivered are becoming the new norm. Putting guidelines in place can improve patient safety, streamline methods of care, lower costs and increase efficiency. Guidelines are especially useful for refining methods of care for high-volume, high-cost or high-risk conditions. The process for guideline implementation, however, can seem daunting, especially when it requires a large number of physicians from various specialties to agree to a single set of guidelines. However, the payoff can be better care and reduced variation — two major goals for healthcare providers. Here are nine best practices for working with evidence-based guidelines at all stages of the process.

1. Let physicians lead the charge. Successful guidelines start with those who provide care, and the most successful programs for implementing evidence-based quality measures rely heavily on clinician participation. Barton Hill, MD, vice president and chief quality officer at St. Luke's Health System in Boise, Idaho, can attest to the importance of the individual clinician in evidence-based medicine. He believes that St. Luke's success with implementing evidence-based guidelines is in large part due to clinicians with a vision of a hospital that practices in the best way it can. "It begins with one person having a passion and making a change," he says.

Oscar Marroquin, MD, director of provider analytics and a cardiologist at University of Pittsburgh Medical Center, agrees. "Physicians are the ones who are going to decide whether we are utilizing our resources in the right way. They have to be at the table, because in our experience, if guidelines are physician-led and guideline content is developed by physicians, we're more likely to succeed."

2. Start small. Adopting evidence-based medicine doesn't have to be an insurmountable undertaking. Dr. Hill's best advice for hospitals looking to start evidence-based quality programs is to start small: Pick one or a few guidelines to investigate and implement, pilot the program results and clearly demonstrate program benefits. Choosing low-hanging fruit right out of the gate is a fine way to start, as it piques interest in evidence-based medicine and demonstrates the value of evidence-based quality guidelines, he says. If the going gets tough, Dr. Hill recommends keeping the ultimate goal of patient safety in mind. "What we want for ourselves and our family — that's the litmus test," says Dr. Hill. "You live in that community, and we all will be patients at some point."

3. Embrace transparency. "Transparency during the guideline creation process is very important. We help everyone understand reasons behind a guideline so they can discuss it and have access to it after it's completed," says Val Slayton, MD, vice president of El Segundo, Calif.-based The Camden Group, a healthcare consulting firm. Ensuring clinicians understand the actual evidence that supports guidelines is also a must. "Providing a rating system for guidelines can help clinicians understand how strong the evidence is," suggests Dr. Slayton.

"We disseminate the guidelines among our clinicians for comment, inviting them to participate in the creation even if they are not a member of the team that created or designed them. If they want a change made, we ask them to support it with evidence from medical literature," says Helen Macfie, PharmD, senior vice president of performance improvement at California-based MemorialCare Health System.

Dr. Hill agrees sharing progress with physicians is important. "One of the keys to success is being transparent. Sharing makes others intrigued and excited and makes people think that progress is worth the discomfort of change," he says.

4. Communicate, communicate and communicate some more. When it comes to evidence-based guidelines, it's impossible to communicate too much. "Sharing results and best practices with our associates creates a smooth process for implementation," says Leslie Simmons, RN, FACHE, president of Westminster, Md.-based Carroll Hospital Center. "For instance, connecting the dots for physicians and staff and showing how following guidelines improve results is vital." According to Mrs. Simmons, Carroll Hospital Center's persistent communication with its staff has been instrumental in eliminating ventilator-related pneumonia for the last four years and central line infections in critical care units the last three years.

It's not always easy, however. "Awareness and communication are always a challenge," says Patricia Davis-Hagens, RN, chief nursing officer and vice president of nursing and site administrator at Mercy Health's Fairfield (Ohio) Hospital.  She recommends trying different modes of communication to attract different demographics of healthcare providers. "Younger employees gravitate towards our electronic bulletin boards, though paper boards seem to work with our more tenured employees," she says. Finding alternate ways to present communication can also be useful. Fairfield Hospital had particular success in reducing patient falls when it personalized fall data to the patient population and publicly displayed information pertaining to the quality goal at hand, including the number of days since the last fall had occurred.

Tim Hannon, MD, MBA, an anesthesiologist and the founder of Indianapolis-based Strategic Healthcare Group, a company devoted to improving blood management, agrees: "It is possible to accelerate the guideline process by being smart, targeting appropriately, communicating, then over-communicating."

5. Add a 'why' to every 'what.' Healthcare providers are smart and motivated and will almost certainly have questions about the necessity of a change. If a compelling rationale is readily available, the guideline process becomes a productive open dialogue. Not every clinician will respond similarly, however. In Dr. Hannon's experience both as an internal physician champion and as an outside consultant, between 15 and 20 percent of physicians will either strongly support or strongly reject a guideline. The other 65 percent are the ideal target population for education. "Allow supporters to be vocal, educate those who are on the fence, and initially resistant clinicians may begin to participate in the change," he says, noting that this bandwagon approach seems particularly effective.

6. Experiment with customization for best results. Just because a guideline exists does not mean it is right for every scenario. Identifying guidelines with potential caveats and working out a strategy to remind clinicians of possible variations is crucial. "There are times when guidelines should not be followed, given the unique patient’s condition. We work to identify those up front and build them right into our online guidelines to make it easy for the clinician to document those exceptions," says Dr. Macfie of MemorialCare.

Another place where customization is crucial is in presenting guidelines: Each hospital must discover which type of presentation works with its staff. Ms. Davis-Hagens shared a particularly compelling example of a successful quality customization. Fairfield Hospital had a guideline for VTE prophylaxis in place, but quality administrators consistently documented less than 50 percent compliance. Physicians were simply forgetting to follow a well-accepted guideline.

"Now that guideline is integrated to our electronic health record system. When we first made a hard stop in the physician order with the guideline, we got to 100 percent compliance within three weeks," Ms. Davis-Hagens says.

7. Consider cost. True evidence-based care does not measure cost at all," notes Dr. Hill. Having infinite resources for providing the best possible care would be ideal, but it is unfortunately never the case. As hospitals increasingly move to value-based payments, physicians will need to examine if a generic drug or lower cost supply can provide similar outcomes at a lower cost. "Ultimately, there will be some trade-offs between better population health outcomes, better care outcomes and lower costs," Dr. Hill says. The trick is deciding how these trade-offs apply for every guideline according to an individual center's institutional goals. Happily for all, it is not unusual for better, more efficient care to go hand-in-hand with lower costs.

8. Ensure guidelines are updated regularly. Even if it's a job well done, the work isn't over once a guideline is in place. "Guidelines must be revisited maybe every year or two to make sure evidence has kept up. You have to keep your guidelines current," says Dr. Slayton of The Camden Group. To maintain and advance quality gains from evidence-based guidelines, hospitals must institute a system for consistent guideline review. Many healthcare centers do this with multiple committees of stakeholders responsible for the upkeep of one or a few guidelines.

9. Show institutional support from leadership. Make commitment to evidence-based guidelines part of the institutional DNA. The bottom line is that evidence-based guidelines eliminate variations in care and give patients the best results scientific evidence can provide. The process is an incredibly collaborative one, and as such it requires robust support from administrators so it can take root, grow and flourish. Among other things, it requires effective administrative mediators and explicit support for clinicians and staff in quality-improvement endeavors.  It's no secret, Dr. Marroquin of UPMC says, that getting consensus from groups of different physicians can sometimes be astonishingly difficult. The administrator's role is to embrace the opportunity to sit in the middle and facilitate the process of reaching an agreement. "Leadership at highest level must say 'this is important, we are going to do this, and we are going to transform ourselves,'" he says.

Institutional support goes beyond mediation, however. Hospitals and hospital systems should strive to establish long-term goals guiding quality improvements. Among hospitals represented here, MemorialCare Health System has instituted safety goals informing the system's patient-centered philosophy on treating conditions with high rates of mortality, frequency or complication. St. Luke's has made a quality-minded triple commitment to be physician-led, have an infrastructure of physician leaders and practice evidence-based medicine where it exists. Carroll Hospital Center not only supports quality improvement within its own institution, but also makes an effort to participate in every Maryland statewide collaborative contributing to research supporting guidelines and best practices in guideline implementation.

Hospital leadership can make permanent quality gains from evidence-based guidelines a reality when it supports its clinicians in improving quality, facilitates discussions among interested parties, makes a commitment to try, reform and maintain guidelines and institutes norms of evidence-based practice. 

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