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


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

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)

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

Bernadette Melnyk, PhD, RN, CPNP/NPP -
ASU Evidence-based Practice in Nursing and
  • 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

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
  • Deciding to develop, adopt, endorse, adapt or not
  • Developing trust,
  • Recognizing competition and need for ownership
  • Measuring uptake and claiming results of
  • 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
  • EHR, clinical decision support systems
  • Translation of comparative effective research
  • Developing CPGs that consider availability of
    health information technology and payment modes

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
  • Within core of truth of best practice universe

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)
What do we do when scientific evidence is absent
or poor? Admit it and move ahead
Reconciling Differences
  • Agree with Pawlson (2009) definition CPGs are
    evidence based statements of optimal (best)
  • 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)

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)

How we accommodate guidelines to subgroups whose
treatment outcomes may differ from average
  • 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)

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
  • Recognition of parent as primary health and care
  • Quest for integrated guidelines provider
  • ASLA
  • ADA
  • And who/how many others
  • CPGs that work in urban, suburban and rural
  • Culturally appropriate CPGs

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

  • Managing nattering nabobs of negativism
  • Safire for Agnew

  • 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

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

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
  • (Ashleigh Brilliant, 1964)

Promoting greater use of guidelines
  • Research utilization, knowledge utilization,
    evidence based practice (EBP research),
    research-based practice, translation researchand
  • 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
  • Anyone using BridgeWiz (Shiffman, Nov 9, 2009 mtg