Knowledge Management and Clinical Practice Guideline Implementation
Jacqueline A. Pugh MD BA
VA South Texas Health Care System
San Antonio, TX
Funding Period: January 2000 - June 2002

BACKGROUND/RATIONALE:
Substantial variability in performance associated with clinical practice guidelines (CPGs) ostensibly results from variation in implementation strategies and from differences in organizational characteristics such as the amount of participation in decision-making and the presence of knowledge enabling conditions. In order to improve VHA primary care compliance with CPGs, it is necessary to identify successful implementation strategies and examine the influence of the organizational context on implementation efforts.

OBJECTIVE(S):
This study examined the influence of organizational barriers and facilitators on efforts to implement clinical practice guidelines (CPG). We sought to investigate the influence of knowledge management on CPG implementation efforts in the context of the amount of participation in decision-making and the presence (or absence) of knowledge enabling conditions in the organizational environment. We hypothesized that performance on External Peer Review Program (EPRP) indicators of guideline performance would increase as the participation in decision-making increases and when the presence of knowledge enabling conditions increased.

METHODS:
We collected data from 15 VAMC facilities (and their associated community-based outpatient clinics) from 4 VISNs. The VISNs were selected based on their overall CPG implementation plan. Within each VISN and using EPRP data, one high performing, one low performing, and two improving (based on the amount of improvement from 1998 to 1999) facilities were selected. Using semi-structured interview guides, qualitative data on mental models, barriers and facilitators, and innovative strategies for implementing guidelines were collected during small group interviews with key personnel. Quantitative survey data on the breadth and depth of participation in decision-making as well as the presence (or absence) of knowledge enabling conditions in the organizational environment were also collected. Chart abstraction data on CPG adherence using EPRP developed measures was also obtained for FY 2001.

FINDINGS/RESULTS:
Chart abstraction is 93% complete. Qualitative data coding is ongoing. Implementation strategies identified to date include: task reassignment among primary care clinic personnel, use of a CPG implementation team, implementation of electronic clinical reminders, data feedback to providers, and provider education. Other themes: Clinical reminders in CPRS are regarded as an effective strategy for improving guideline adherence but their successful implementation at the local level (because they require customization) is facilitated by the clinical applications coordinator having clinical as well as technological expertise. Local, interdisciplinary teams tasked with guideline implementation facilitate adherence by providing both structure and guidance. Insufficient staffing and too little time are perceived as significant barriers for conforming to the guidelines. From the perspective of the provider, support from leadership is also considered integral to guideline implementation. Simple mandates in the absence of support and resources may result in a “forced to fraud” documentation of guideline adherence. We anticipate the emergence of even more strategies as coding is completed. The next step will be to link these data to the chart abstraction data when complete. Analysis of the quantitative survey data has begun with exploratory factor analyses of the knowledge enabler instrument. Preliminary results suggest a robust, two-factor structure. Once the remaining chart abstraction data are obtained, we will be able to formally test our research hypotheses about the relationship between both participation in decision-making and the presence of knowledge enablers and success with guideline adherence.

IMPACT:
Implementation strategies associated with high or improving performance will be disseminated via multiple methods throughout the VHA, potentially leading to even greater quality of medical care to our veterans. In addition, ability to measure organizational characteristics associated with CPG adherence will facilitate development of generic (non-disease specific) strategies for organizational change.

PUBLICATIONS:

Journal Articles

1. Hysong SJ, Best RG, Pugh JA. Clinical practice guideline implementation strategy patterns in Veterans Affairs primary care clinics. Health Services Research. 2007; 42(1 Pt 1): 84-103.
2. Best RG, Hysong SJ, Pugh JA, Ghosh S, Moore FI. Task overlap among primary care team members: an opportunity for system redesign? Journal of Healthcare Management / American College of Healthcare Executives. 2006; 51(5): 295-306; discussion 306-7.
3. Hysong SJ, Best RG, Pugh JA, Moore FI. Not of one mind: mental models of clinical practice guidelines in the Veterans Health Administration. Health Services Research. 2005; 40(3): 829-47.
4. Best RG, Hysong SJ, McGhee C, Moore FI, Pugh JA. An empirical test of Nonaka's theory of organizational knowledge. E-Journal of Organizational Learning and Leadership. 2003; 2(2): 1-19.

DRA: Chronic Diseases, Health Services and Systems
DRE: Communication and Decision Making, Quality of Care
Keywords: Behavior (provider), Clinical practice guidelines, Primary care
MeSH Terms: Evidence-Based Medicine, Knowledge, Attitudes, Practice, Practice Guidelines, Primary Health Care, Quality of Health Care, United States Department of Veterans Affairs, Ambulatory Care Facilities, Decision Making, Organizational, Delivery of Health Care, Guideline Adherence, Health Services Research, Organizational Culture