Time Tested Guideline Development and Implementation : The Institute for Clinical Systems Improvement (ICSI) Collaborative Process © 2007 Institute for Clinical Systems Improvement Cally Vinz, RN - Director Evidence Based Health Care, ICSI AHRQ Annual Conference, September 2007

2 Who is ICSI?  Established in 1993  A collaborative of 61 member organizations that include medical groups, hospitals and integrated systems  Sponsored by six non-profit health plans

Mission Champion the cause of health care quality and to accelerate improvement in the value of the health care we deliver. We aim to make health care: Patient-centered and Value-driven

Clinical Patient & Family GuidelinesGuidelines Evidence-based statements of how to prevent, detect, or treat a specific health condition taking into account the preferences of the patient and his or her family. The same clinical guidelines developed for health care providers, supplemented by definitions and descriptions of medical terms that are often unfamiliar to people who are not health care professionals.

Order SetsProtocols Standardized instructions to manage a disease, condition or procedure Presented as a set of orders to be individually selected and signed by an authorized prescriber Step-by-step statement of a routine procedure To assure intended effect is reliably achieved

Process Multidisciplinary & multi-organizational workgroup Systematic process for reviewing evidence, regulatory requirements and existing practices Development of algorithm and annotations (citing graded evidence) — Consensus process to support standardization

Process (cont.) Develop implementation and measurement recommendations Review and feedback by member organizations Respond to comments, revise & release for use Updated every months

Guideline Sections Algorithm & Annotations Supporting Evidence Implementation Recommendations

10 Where we started: “Sure bet” guidelines Clinical issues with enough evidence Creating many guidelines per year Expecting all guidelines to be implemented

11 What we learned: “Guidelines do not implement themselves” (Field and Mohr, 1992) Implementation support - Quality improvement education - Collaborative implementation Implementation recommendations Measurement

12 Where we are now: Topics with less definitive evidence Implementation recommendations growing More stakeholders involved (patients, employers, plans, DHS,etc)

Collaborative Implementation Strategies Successful Collaborative Implementation Requires: Systems approach Change management strategies & culture work Improvement support Transparent measures Make it easy to do the right thing!

14 Topics we are now addressing:  Palliative Care  Primary Prevention of Chronic Disease  Reliability Centered Surgical Care (protocols)

15 Where we are going: Redesigning guidelines – Decision support recommendations – Making recommendations of what to do and NOT to do – Incorporate value recommendations (cost & effectiveness) – Considerations for EMR’s – Human factors – Reliability concepts

16 Where we are going: Use the power of the collaborative – Identify transformational margins – Involve all stakeholders – Payment reform ? Adapting guidelines developed elsewhere

Redesigning Health Care DIAMOND ( Depression Improvement Across Minnesota, Offering a New Direction ) High Technology Diagnostic Imaging Reliability Centered Surgical Care Palliative Care

18 Summary Guidelines must be in an implementable format It takes all stakeholders to make guidelines relevant With collaboration, we go further, faster Sustained implementation requires redesign