Determination of Clinical Implementation Effectiveness
Bradley N. Doebbeling MD MSc
Richard Roudebush VA Medical Center
Indianapolis, IN
Funding Period: July 1999 - June 2001

BACKGROUND/RATIONALE:
Despite growing numbers of available clinical guidelines (CG), there has been little systematic investigation concerning effective mechanisms to implement the CGs into practice. Our research investigates the relationship between VA facilities’ organizational characteristics, implementation structures and processes, and effective CG implementation.

OBJECTIVE(S):
The specific aims are to: 1) describe rates of adherence with current CGs in acute care facilities; 2) identify factors (organizational structures, implementation approaches, etc.) associated with effective dissemination of, and adherence with CGs; and 3) develop and validate predictive models of the relationships between organizational characteristics, CG characteristics, and CG implementation processes, with outcomes, especially provider adherence.

METHODS:
This multi-method, quasi-experimental national study utilizes qualitative and quantitative methods. National patient survey and chart audit performance data assessed consistency of ranking in adherence across multiple CGs. Selected VAMCs represented a range of adherence, geographic, bed-size, teaching affiliation, patient gender, and ethnic distributions. Fifty focus groups (16 physician, 17 administrator and 17 other clinician groups, N= 322), were conducted in 18 VAMCs to identify important organizational barriers and facilitators to implementation. A system wide Performance Improvement Coordinator (PIC) survey was used to examine organizational context, dissemination mechanisms, monitoring, feedback, provider knowledge, attitudes and compliance. Data analyses led to development of a survey to assess provider-level factors influencing CG adoption and adherence.

FINDINGS/RESULTS:
We developed and compared alternate methodologies for benchmarking institutional performance across multiple performance measures. Physician, clinician and administrator focus groups varied with regards to their attitudes and perceptions of barriers and facilitators to CG implementation. Qualitative analyses indicated that guidelines need to be simple, clear and valid. The guidelines must fit into contemporary practice, change quickly as new clinical evidence evolves, but not be under constant clinical change. Technologic and human resources for automation of reminders and documentation are required. Accountability (internal audits and feedback) contribute to guideline implementation within a facility. The PIC survey (N= 126 facilities, 91%) demonstrated wide variation in dates and approaches to implementation, organizational context, and guideline specific factors. Factors such as interdisciplinary teamwork, technology, a structured implementation process, feedback, and administrative support were considered important to implementation.

IMPACT:
Institutional and system-level organizational factors, guideline and implementation-process factors, and individual provider-level factors all appear to be important in facilitating effective clinical practice guideline implementation. These results will advance the QUERI directive of translating research into practice by identifying effective approaches to CG implementation and lead to improved health care for veterans.

PUBLICATIONS:

Journal Articles

1. Subramanian U, Sutherland J, McCoy KD, Welke KF, Vaughn TE, Doebbeling BN. Facility-level factors influencing chronic heart failure care process performance in a national integrated health delivery system. Medical Care. 2007; 45(1): 28-45.
2. Ward MM, Yankey JW, Vaughn TE, BootsMiller BJ, Flach SD, Watrin S, Doebbeling BN. Provider adherence to COPD guidelines: relationship to organizational factors. Journal of Evaluation in Clinical Practice. 2005; 11(4): 379-87.
3. Ward MM, Diekema DJ, Yankey JW, Vaughn TE, BootsMiller BJ, Pendergast JF, Doebbeling BN. Implementation of strategies to prevent and control the emergence and spread of antimicrobial-resistant microorganisms in U.S. hospitals. Infection Control and Hospital Epidemiology. 2005; 26(1): 21-30.
4. BootsMiller BJ, Yankey JW, Flach SD, Ward MM, Vaughn TE, Welke KF, Doebbeling BN. Classifying the effectiveness of Veterans Affairs guideline implementation approaches. American Journal of Medical Quality. 2004; 19(6): 248-54.
5. Tripp-Reimer T, Doebbeling B. Qualitative Perspectives in Translational Research. Worldviews on evidence-based nursing / Sigma Theta Tau International, Honor Society of Nursing. 2004; 1(Supplement 1): S65-S72.
6. Flach SD, McCoy KD, Vaughn TE, Ward MM, Bootsmiller BJ, Doebbeling BN. Does patient-centered care improve provision of preventive services? Journal of General Internal Medicine. 2004; 19(10): 1019-26.

DRA: Health Services and Systems
DRE: Communication and Decision Making, Quality of Care
Keywords: Behavior (provider), Clinical practice guidelines, Organizational issues
MeSH Terms: none