guideline implementation: opportunities challenges
TRANSCRIPT
Tisa Vorce RRT, MAMichigan Department of Community Health
[email protected] 517.335.9463
AIM Partnership Forum – May 31, 2012
Guideline Implementation: Opportunities & Challenges
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.
Useinhaledcorticosteroids tocontrolasthma. Usewrittenasthmaactionplans toguidepatientself‐management.
Assessasthmaseverity attheinitialvisittodetermineinitialtreatment.
Assessandmonitorasthmacontrol andadjusttreatmentifneeded.
Schedulefollowupvisits atperiodicintervals. Controlenvironmentalexposures thatworsenthepatient’sasthma.
Guideline Implementation Panel (GIP) ReportKey Messages
ProgramdevelopedbyAIMProjectTeam,includingasthmaandpracticeredesignexperts
Goal:tohelpcliniciansmakediagnosisandcaredecisionsbasedontheEPR‐3asthmaguidelines,andincorporatethesetoolsintotheireverydaypractice
DevelopmentanddisseminationfundedbyNationalAsthmaControlInitiative(NACI)
Nowavailablefordistributionandimplementationinanyprimarycarepractice
“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
Action Plans, Medication & Education
Important! GetAsthmaHelp.org/GIST AsthmaActionPlans,medicationhandoutsandeducationalinformation
ToolsandresourcesforGISTimplementation
2011 – Two Pilot Practices
Learnedalotabouthowpracticeswork Sawimprovementsinonepractice‐ hadmotivatedphysicianchampion,committedofficemanager,experienceinQIactivities
Theotherfailedtoimplementeffectively→noimprovement.Physiciannotachampion,officemanagertriedtodoitall,staffnotmotivatedtochange
BothhadEMRissues
Implementation Challenges
Forbothpractices
Peak‐flowbasedAAP ImplementingpracticenowusingUMAAP
Gettingallthecliniciansonboard Implementingphysicianchampionabletouseoutcomemeasurestogainbuy‐in
ForthepracticethatimplementedGIST
Jugglingforms‐ whogetswhatwhen? UseACTscoretoindicateneedforFollow‐UpToolatnon‐asthmavisit
EMRs
Subjective Feedback
Alittletimeconsumingifpatientcameinfrequently‐ learnedhowtoadaptsystemtohandlethat
Docsdon’tliketobetoldwhattodo…buteasiertosellGISTbecause“justlikeNIHguidelines”
Seedifferenceinpracticebehavior,notjustinreporting
Measurementwasarealwakeupcall AAPcanbeimportantopportunitytolearn
howpatientactuallyhandlesasthmasymptoms
GIST Champions Project
ProvidedsmallincentivestophysicianchampionstopromoteGISTandasthmaQIin5newprimarycarepracticesfor6months Staffandcliniciantrainings StartedsomeQIactivities,ACT EMRchallenges
Commitmentfromallstaff,needphysicianchampion Emphasizepracticereviewofdatawithimplementation Musthaveuseful/belovedAAP Practicemustbecommittedtoroutine,notjustepisodic
asthmacare Changesmayneedtobeinbabysteps ImportanceofEMRanddifficultyofEMR Needforimplementationresources:
alwaysgrowingatGetAsthmaHelp.org/GIST
Lessons Learned
Next Steps
NeedhelppromotingGIST– howcanyouhelp? GISTinEMRs GISTinphysicianspecialtyaccreditation Findfundingfornextsteps…
Why Asthma?
Asthma QITargets: Severityandcontrolassessments
ACTtoassessasthmacontrol
Prescriptionofinhaledsteroids
Useofasthmaactionplans
Educationalsessions
Outcomes ACTusehasimprovedto50%‐ targetwas75%
Educationalsessionsweresuccessful,wellliked
Challenges Systemfactors
Personnelfactors
Physicianfactors
Patientfactors
System factors
Personnel factors
Physician factors Residentsandfacultywerenotawareofthenewguidelines
Onlyoneslotforgrandroundsforresidenteducation
Residentschedulesondifferentdays
Lackofcontinuityaffectingmedicalrecords
Multiple responsibilities
My project not our project
Fellowship + SOBRAP + GIST
Regular duties
Patient factors Noplannedvisits
Multiplemedicalproblemstoaddressinsinglevisit
Asthmaadoorknobcomplaint
Notenoughnumbers‐ actsofGod?
Educational sessions
Next stepsEveryjourneybeginswithasmallstep
Thank You