Guideline Implementation: Opportunities Challenges
Transcript of Guideline Implementation: Opportunities Challenges
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Tisa Vorce RRT, MAMichigan Department of Community Health
[email protected] 517.335.9463
AIM Partnership Forum – May 31, 2012
Guideline Implementation: Opportunities & Challenges
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GuidelinesAvailable
GuidelinesUsed
Lackofawareness Lackoffamiliarity Lackofagreement Lackofself‐efficacy,time Lackofoutcomeexpectancy Inertiaofpreviouspractice
Barriers pediatricians face when using asthma practice guidelines.Arch Pediatric Adolescent Med 2000 Jul;154(7):685‐93.
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Useinhaledcorticosteroids tocontrolasthma. Usewrittenasthmaactionplans toguidepatientself‐management.
Assessasthmaseverity attheinitialvisittodetermineinitialtreatment.
Assessandmonitorasthmacontrol andadjusttreatmentifneeded.
Schedulefollowupvisits atperiodicintervals. Controlenvironmentalexposures thatworsenthepatient’sasthma.
Guideline Implementation Panel (GIP) ReportKey Messages
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ProgramdevelopedbyAIMProjectTeam,includingasthmaandpracticeredesignexperts
Goal:tohelpcliniciansmakediagnosisandcaredecisionsbasedontheEPR‐3asthmaguidelines,andincorporatethesetoolsintotheireverydaypractice
DevelopmentanddisseminationfundedbyNationalAsthmaControlInitiative(NACI)
Nowavailablefordistributionandimplementationinanyprimarycarepractice
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“QuestionsAboutYourBreathing”or
“AsthmaControlTest™”
“AsthmaDiagnosisTool”or
“AsthmaPatientFollow‐UpTool”
“StepwiseApproachtoManagingAsthma”
AsthmaGuidelineImplementationSteps&Tools(GIST)AprovidereducationandpracticeredesignprojectbytheMichiganDepartmentofCommunityHealthbasedonthe2007NAEPPAsthmaGuidelines.GISTmakesiteasierforprimarycareclinicianstousetheasthmaguidelinesintheireverydaycareofpatientswithasthma.VisitGetAsthmaHelp.org/GISTformoreinformation.
Givenpriortoseeingclinician• Gets“Questions”formifbeingseenforrespiratorycomplaints‐ historyandsymptomquestionnaire
•“ACT™”formforreturningasthmapatient,patientcontrolassessment
Patientwithclinician,whouses:•“Diagnosis”formifpatientinforrespiratorycomplaints‐ diagnoses/rulesoutasthma,findsseveritylevelifasthma,stepcarestarted
• “Follow‐Up”formforreturningasthmapatient‐ findscontrollevel,stepsup,downormaintainsasneeded
• UseStepwiseApproachtofindmedicationneeds,managementapproach• Opportunityforpatiented aboutasthmatriggers,meds,barriers,etc.• Patientreceivesprescription(s)andAsthmaActionPlan• NospecifiedAAPforGIST,manygoodonesavailableatGetAsthmaHelp.org
Monitorprogressbytrackingtheseorotheroutcomes:• numberofasthmapatientsinpractice• number(or%)ofasthmapatientswithcurrentasthmaactionplan• number(or%)ofasthmapatientswithcontrolassessmentatlastvisit• number(or%)ofasthmapatientswithappropriateprescriptionofICS
Evaluate,improvesystem,
repeat
AsthmaActionPlan,Ed&Meds
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Action Plans, Medication & Education
Important! GetAsthmaHelp.org/GIST AsthmaActionPlans,medicationhandoutsandeducationalinformation
ToolsandresourcesforGISTimplementation
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2011 – Two Pilot Practices
Learnedalotabouthowpracticeswork Sawimprovementsinonepractice‐ hadmotivatedphysicianchampion,committedofficemanager,experienceinQIactivities
Theotherfailedtoimplementeffectively→noimprovement.Physiciannotachampion,officemanagertriedtodoitall,staffnotmotivatedtochange
BothhadEMRissues
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Implementation Challenges
Forbothpractices
Peak‐flowbasedAAP ImplementingpracticenowusingUMAAP
Gettingallthecliniciansonboard Implementingphysicianchampionabletouseoutcomemeasurestogainbuy‐in
ForthepracticethatimplementedGIST
Jugglingforms‐ whogetswhatwhen? UseACTscoretoindicateneedforFollow‐UpToolatnon‐asthmavisit
EMRs
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Subjective Feedback
Alittletimeconsumingifpatientcameinfrequently‐ learnedhowtoadaptsystemtohandlethat
Docsdon’tliketobetoldwhattodo…buteasiertosellGISTbecause“justlikeNIHguidelines”
Seedifferenceinpracticebehavior,notjustinreporting
Measurementwasarealwakeupcall AAPcanbeimportantopportunitytolearn
howpatientactuallyhandlesasthmasymptoms
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GIST Champions Project
ProvidedsmallincentivestophysicianchampionstopromoteGISTandasthmaQIin5newprimarycarepracticesfor6months Staffandcliniciantrainings StartedsomeQIactivities,ACT EMRchallenges
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Commitmentfromallstaff,needphysicianchampion Emphasizepracticereviewofdatawithimplementation Musthaveuseful/belovedAAP Practicemustbecommittedtoroutine,notjustepisodic
asthmacare Changesmayneedtobeinbabysteps ImportanceofEMRanddifficultyofEMR Needforimplementationresources:
alwaysgrowingatGetAsthmaHelp.org/GIST
Lessons Learned
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Next Steps
NeedhelppromotingGIST– howcanyouhelp? GISTinEMRs GISTinphysicianspecialtyaccreditation Findfundingfornextsteps…
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Why Asthma?
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Asthma QITargets: Severityandcontrolassessments
ACTtoassessasthmacontrol
Prescriptionofinhaledsteroids
Useofasthmaactionplans
Educationalsessions
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Outcomes ACTusehasimprovedto50%‐ targetwas75%
Educationalsessionsweresuccessful,wellliked
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Challenges Systemfactors
Personnelfactors
Physicianfactors
Patientfactors
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System factors
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Personnel factors
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Physician factors Residentsandfacultywerenotawareofthenewguidelines
Onlyoneslotforgrandroundsforresidenteducation
Residentschedulesondifferentdays
Lackofcontinuityaffectingmedicalrecords
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Multiple responsibilities
My project not our project
Fellowship + SOBRAP + GIST
Regular duties
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Patient factors Noplannedvisits
Multiplemedicalproblemstoaddressinsinglevisit
Asthmaadoorknobcomplaint
Notenoughnumbers‐ actsofGod?
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Educational sessions
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Next stepsEveryjourneybeginswithasmallstep
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Thank You