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Organizational and Clinical Factors Influencing Use of Clinical Practice Guidelines

Tamara T. Stone, Ph.D., University of Missouri-Columbia
Seema S. Sonnad, Ph.D., University of Michigan
Sharon B. Schweikhart, Ph.D., The Ohio State University

Clinical practice guidelines can be effective towards reaching common system goals of improved patient care management.  Identifying and overcoming institutional and operational barriers can help ensure the successful implementation of guidelines.

Implementing clinical practice guidelines can improve the quality of patient care and positively impact a health care system’s bottom line.  To increase the chances of successful implementation, a study by Dr. Stone and her colleagues examines ways that guidelines can be tailored to better meet physicians’ needs and also suggests strategies that encourage guideline acceptance.

The first phase of the study surveyed almost 500 physicians from four health systems when two guidelines (one for acute myocardial infarction and the other for pediatric asthma) were implemented.  Researchers asked physicians exactly where they preferred that the guidelines be placed and what specific learning strategies best encouraged them to use the guidelines.  They also asked about the content areas, formats, and types of medical evidence that physicians found most useful as they treated patients.

Survey results revealed that, overall, physicians preferred that guidelines be placed on the front of the patient chart, on their personal palm pilots, or in the progress notes.  Discussions with colleagues and continuing medical education were identified as most effective in encouraging guideline implementation.  During patient treatment, physicians considered guidelines that included immediate treatment flows and strategies aimed at minimizing and encouraging self-management to be the most useful.  Clinical guidelines presented in the form of flowcharts, algorithms, and pre-printed orders were also judged more convenient to use when treating patients, and randomized controlled trials were the most persuasive medical evidence that could be included in a guideline.

The following are some of the negative physician viewpoints uncovered by Dr. Sands and her colleagues:

  • Physicians judged departmental memos and electronic newsletters as ineffective tools for educating or encouraging them in the use of new guidelines.
  • Disease- or illness-specific pamphlets were not considered useful formats for disseminating clinical treatment information to patients at the time of treatment.
  • Although citing references was viewed as an important part of the guideline development process, physicians felt that references were unnecessary for inclusion in guidelines used at the time of treatment.

The second phase of Dr. Sands’ study examined how the four participating health systems approached guideline development and implementation.  Among their general findings, researchers discovered that successful implementation of clinical guidelines within a system was facilitated by:

  • physician champions who were included in guideline development and dissemination efforts;
  • data systems that allowed measurement of specific patient populations at the level of the clinical encounter;
  • implementation methods that embedded guideline recommendations into existing patient care routines;
  • management who understood the guideline process and supported it with personnel and data resources;
  • guidelines that were integrated with other methods and programs important to the system's primary strategic goals.

Ultimately, guidelines benefit the system, the physician, and the patient by improving the quality of care and controlling costs.  Insight into organizational and clinical factors will assist health system leadership overcome barriers and facilitate success when implementing clinical practice guidelines.

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