IOM Workshop on Standards for Clinical Practice Guidelines January 11, 2010 - PowerPoint PPT Presentation

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IOM Workshop on Standards for Clinical Practice Guidelines January 11, 2010

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IOM Workshop on Standards for Clinical Practice Guidelines January 11, 2010 Presentation to Committee on Standards for Developing Trustworthy CPGs – PowerPoint PPT presentation

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Title: IOM Workshop on Standards for Clinical Practice Guidelines January 11, 2010


1
IOM Workshop on Standards for Clinical Practice
Guidelines January 11, 2010
  • Presentation to Committee on Standards for
  • Developing Trustworthy CPGs
  • Karen KellyThomas, PhD, RN, FAAN
  • CEO
  • National Association of
  • Pediatric Nurse Practitioners (NAPNAP)

2
Scope of presentation/perspective
  • NAPNAP Healthy Eating and Activity Together
    (HEATsm) Program and CPG
  • NAPNAP Keep Yourself/Your Children Safe and
    Secure (KYSS sm) Program and outcomes
  • AWHONN RBP Program and projects
  • 1996-2003
  • Reference List for 4 projects
  • Research and Development in 4 hospitals
  • 1975-1996

3
Bernadette Melnyk, PhD, RN, CPNP/NPP -
ASU Evidence-based Practice in Nursing and
Healthcare
  • Melnyk et al Seven Steps
  • Step 0 - Cultivate a spirit of inquiry
  • Step 1 - Ask clinical question in PICOT format
    (population, area of interest, comparison
    intervention or group, outcome, time)
  • Step 2 - Search for the best evidence
  • Step 3 - Critically appraise the evidence
  • Step 4 Integrate the evidence with clinical
    expertise and patient preferences and values
  • Step 5 Evaluate the outcomes of the practice
    decisions or changes based on evidence
  • Step 6 Disseminate the result
  • Other models in use i.e. Titler/Iowa
    Stevens/UTHSA

4
The biggest challenges facing developers
today Confessions of a contingency theory based
and pragmatic CEO
  • Finding right people, time and money learning up
  • Determining clinical discipline and practice
    specificity
  • Deciding to develop, adopt, endorse, adapt or not
  • Developing trust,
  • Recognizing competition and need for ownership
  • Measuring uptake and claiming results of
    implementation
  • Branding, creative packaging and access for
    clinician users
  • Participating in the relentless quest for
    sustainability or barbecuing a sacred cow
  • Managing fear of the unknown and interfaces
    necessary
  • EHR, clinical decision support systems
  • Translation of comparative effective research
  • Developing CPGs that consider availability of
    health information technology and payment modes

5
Within our known healthcare universe,
environment, systems, and contexts within
  • Looming EHRs meaningfully used
  • Principles of transparency
  • Knowledge of performance measures
  • Knowledge of gaps and limitations
  • Political, science and human communities
  • The activities as forethought
  • Within knowledge that stopping is harder than
    starting
  • Within core of truth of best practice universe

6
Yet knowing life feels more like a gyroscope
teetering toward more knowledge and stronger
trust Never trust the teller. Trust the tale.
(D.H. Lawrence)
7
What do we do when scientific evidence is absent
or poor? Admit it and move ahead
8
Reconciling Differences
  • Agree with Pawlson (2009) definition CPGs are
    evidence based statements of optimal (best)
    practices
  • Value IOM (1990) definition Clinical practice
    guidelines are systematically developed
    statements to assist the practitioner and patient
    decisions about appropriate health care for
    specific clinical circumstances
  • Use a systematic process
  • Empower science teams to decide
  • Trust spirit of volunteer commitment
  • Trust clinical judgment of expert and experienced
    clinicians (and intuitionwith recognition)

9
Reconciling disagreements
  • Select a schema to appraise evidence quality and
    stick to it
  • Avoid every impulse to create another schema or
    scoring method (82 is enough!)
  • Encourage lusty debate that informs all team
    members and others
  • I think we may safely trust a good deal more than
    we do (Emerson)

10
How we accommodate guidelines to subgroups whose
treatment outcomes may differ from average
patient
  • Pediatric population as primary group
  • Accommodation as standard in well child visits,
    anticipatory guidance, and EPSDT
  • Body of knowledge about children with special
    healthcare needs
  • AHRQ draft Core Set of Child Healthcare Quality
    Measures for Medicaid and CHIP Programs NAPNAP
    involvement and public comments (March1, 2010)

11
Other important challenges
  • Child-focused interdisciplinary guidelines that
    identify contributions of different providers
    providing same care
  • Recognition of childs healthcare home and
    multiple primary healthcare providers scope of
    practice
  • Recognition of parent as primary health and care
    provider
  • Quest for integrated guidelines provider
    inclusive
  • ASLA
  • AAP/AAFP
  • ADA
  • And who/how many others
  • CPGs that work in urban, suburban and rural
    settings
  • Culturally appropriate CPGs

12
NAPNAP recommendations for CPG Guideline Panel
Membership
  • Must be Provider inclusive
  • Balance membership of
  • diverse clinical experts
  • Methodologists
  • parent/consumers
  • Consider including an interpretive-hermeneutic
    researcher

13
  • Managing nattering nabobs of negativism
  • Safire for Agnew

14
Consider
  • Methods for selecting recommendations to apply
    CQI measures identified as part of process, tag
    and prioritize, challenge the best testers with
    incentives, continuously define clinical
    effectiveness measures
  • Available rating/assessment tools rank those
    available, recognize patterns, be pragmatic,
    polish the tarnished silver, dont throw babe
    out with bathwater
  • Keep using the words credible and trust - it
    goes both and all ways
  • Development of economics of it all and true
    stakeholders of it all

15
Administrative, accreditation, or legal
approaches that might improve the quality of CPGs
  • Create and disseminate a briefing for stakeholder
    administrators that will inform
  • Promote AHRQ Guideline Clearing House
  • If GLIA (Implementability Assessment) has
    validity and reliability, push out to
    associations who develop guidelines with care to
    include developers of a few and developers of
    many of diverse healthcare providers
  • Disseminate AVUL (ambiguous, vague,
    underspecified language) as strategy for
    guideline developers
  • Reduce the size of the black box of electronic
    guideline knowledge representation
  • Do not develop an accreditation process for a
    few if developed process must be applicable to
    all developers

16
Harmonizing and converging guidelines
  • Bring diverse groups together then send them out
  • Expand opportunities for professional societies
    to develop and become PBRNs as underframe
  • Call the best of the best to action
  • Be careful what you ask for
  • Other characteristics of guideline standards that
    are important
  • I may not be perfect, but parts of me are
    excellent
  • (Ashleigh Brilliant, 1964)

17
Promoting greater use of guidelines
  • Research utilization, knowledge utilization,
    evidence based practice (EBP research),
    research-based practice, translation researchand
    on
  • Use decades of acquired knowledge to create more
    champion opportunities for more developers to
    come together then push out
  • Go forth and disseminate
  • Pay attention to the need for the proverbial
    resources
  • Anyone using BridgeWiz (Shiffman, Nov 9, 2009 mtg
    presentation)
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