evidence-based clinical practice guidelines (cpgs) adaptation & implementation in hospitals of...

بســـــم الله الرحمـــــن الرحـــــيم

In the name of Allah. Most Gracious, Most Merciful

05/01/2023 2

Evidence-Based Clinical Practice Guidelines (CPGs)

Adaptation & Implementation in Hospitals of Two

Universities in MENA

Presented ByDr. Yasser Sami Amer, MBBCh, MS

MS Pediatrics, MS Healthcare InformaticsHospital CPGs Advisor, EBRU, QMD KSUMC

General Coordinator, Hospital-Wide CPG CommitteeMember, G-I-N Adaptation WG steering grou

From Alexandria University Hospitals in Egypt to King Saud University in

Saudi Arabia

1999

2006

2004

05/01/2023 CPGs Adaptation & Implementation in KSUMC: KAUH 2014

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First Postgraduate Master thesis in [Clinical Practice Guidelines Adaptation & Implementation]

in Alexandria University Faculty of Medicine, Egypt

Alexandria University HospitalsHealthcare Quality Directorate

Center for Evidence-Based Clinical Practice Guidelines

(AUH – HCQD, CEBCPGs)(Founded Nov. 2008)

http://www.med.alexu.edu.eg/cebcpgs/ Member of Guidelines International Network

(G-I-N)(Since May 2009)

http://www.med.alexu.edu.eg/cebcpgs/

http://www.med.alexu.edu.eg/cebcpgs/

2005• It all started with a• VISION…….. a DREAM !

2007• Then a Thesis

2008• Then a Foundation………• A Reality ! ………..CEBCPGs

History of the Center

IS THE SECOND MEMBER OF G-I-N FROM THE MIDDLE EAST, ARAB & AFRICAN COUNTRIES;

AFTER SUDAN EVIDENCE-BASED ASSOCIATION (SEA) SINCE 2009.

(ACCORDING TO G-I-N ANNUAL REPORT 2009)

Founding Members 2008• Prof. Dr. Mahmoud Elzalabany• Prof. Dr. Tarek Omar• Prof. Dr. Nabil Dowidar• Prof. Dr. Afaf Ibrahim• Dr. Yasser S. Amer• Dr. Hossam Ashour• Eng. Ahmed Mourady

First Workshop in Egypt: Adaptation of CPGs2009 (AFM-GIN-ADAPTE)

*12 M.Sc. Theses plus 1 Ph.D. thesis to produce 13 Adapted EBCPGs

4 Finalized Adapted CPGs by CEBCPGs, HCQD-AUHs through MSc Theses (till 3/2012) in PEDIATRICS DEPT.:1- Treatment of Acute Childhood Asthma in ER - AUCH: Dr. Yasser Sami Amer (Finalized, Approved , Disseminated & Implemented).2- Treatment of Positioning & Attachment Breast Feeding Problems in BFCC - AUCH: Dr. Georgina Ramsis (Finalized & Approved).3- Triage and Acuity Scale in A & E Dept., AMUH: Dr. Mary Christeen Nabiel Sharobeem (Finalized, Approved & Disseminated ) – the only thesis outside the Pediatrics Dept.4- Treatment of HIE in Neonates in NICU: Dr. Walid Gamal AbdelKhaliq (Finalized & Approved).5- Treatment of ADHD in children in AUCH: Dr. Mariana Iskander Amin (Finalized & Approved).6-Management of Acute Bacterial Meningitis in AUCH: Dr Mariam Adly (Finalized & Approved).9 Adapted CPGs in progress by Pediatrics Dept. & CEBCPGs, HCQD-AUHs through MSc/PhD Theses (till 8/2012):1. Diagnosis of acute attack of seizures in AUCH: Dr. Soheir Farouk AbdelSalam

(Finalization Phase).2. Treatment of acute attack of seizures in AUCH : Dr. Islam Yousry A.Moneium (Set Up

Phase).3. Management of Epilepsy in children in AUCH: Dr. Shimaa Anwar (Set Up Phase)4. Treatment of Childhood Autism in AUCH: Dr. Farioz Ibrahim (Finalization Phase).5. Treatment of Chronic Asthma in AUCH: Dr. Reem Galal Ghazal (Finalization Phase).6. Treatment of Community Acquired Pneumonia in AUCH: Dr. Zobaida Eltazmany

(Finalization Phase).7. Treatment of Allergic Rhinitis in AUCH: Dr. Shahinaz (Set Up Phase).


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WHO Patient Safety Friendly Hospital Initiative in the Eastern Mediterranean Region

Alexandria University Children’s Hospital

G-I-N 2009 Lisbon

G-I-N 2012 Berlin


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“The Adapted ADAPTE Process for CPGs Adaptation”


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3 New Tools3 Modified Tools

For the Guideline Adaptation: A Resource Toolkit Version 2.0


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http://qualitysafety.bmj.com/content/22/Suppl_1/43.1.abstract?sid=302fcfca-c444-4bd3-a295-c75c811b7d49 (last cited 7/6/2014 in BMJ Quality & Safety)

http://qualitysafety.bmj.com/content/22/Suppl_1/43.1.abstract?sid=302fcfca-c444-4bd3-a295-c75c811b7d49



05/01/2023 32

Evidence-Based Clinical Practice

Guidelines (CPGs)Adaptation &

Implementation Program Launching CPGs Implementation

in King Saud University Medical City

(KSUMC) Presented ByDr. Yasser Sami Amer, MBBCh, MS

MS Pediatrics, MS Healthcare InformaticsHospital CPGs Advisor, EBRU, QMD KSUMC

General Coordinator, Hospital-Wide CPG CommitteeMember, G-I-N Adaptation WG steering grou


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KSUMC CPG PROGRAMcurrent status 2013 – 2014

Antibiotic Prophylaxis in Surgery 34

Clinical Practice Guidelines (CPGs) Program of King Saud University Hospitals/ Medical City

KSUHs Taskforce Responsible Staff from:Clinical Practice Guidelines Committee;Quality Management Department;Clinical Departments (CPGs subcommittees);Shaikh Abdullah Bahamdan Research Chair for Evidence-

Based Health Care and Knowledge Translation;Top Management & Leadership of College of Medicine

and University Hospitals (Future KSU Medical City)

09 JAN 2014

CPG Program Relations (integration)

HOSPITAL-WIDE CLINICAL PRACTICE GUIDELINES COMMITTEE (July 2009)

QT

EBHC-KT

QMD

KSUMC CPGs Program

Guidelines International Network (G-I-N)www.g-i-n.net

EBHC-KT Chair, King Saud UniversityOrg. Member since 2009

(1st Member from Gulf & 3rd Member from MENA Countries)

Founded in Nov. 2002

http://www.g-i-n.net/

KSUMC CPGs in Numbers Hospital-Wide CPG Committee Members: 27 Departments participating in CPG Program: 21 Health topics identified for CPG projects: 53 CPG adaptation projects finalized: 33 CPGs finalized & approved by CPG Committee: 19 CPGs finalized & implemented: 17 CPGs uploaded to QM website & relevant desktop in points of

care: 17 CPGs implemented & audited (data collected): 8 CPGs implemented & audited (data analyzed): 3


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Who is the contact person for EBCPGs in your department?

Head, Department CPG Subcommittee Members, Department CPG Subcommittee Department Quality Focus teams (former

Accreditation teams) Hospital CPG Advisor and CPG Committee General

Coordinator Medical Secretary, Hospital CPG Committee


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Pediatrics

+1 CPG reviewed


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Critical Care (ICU)

+1 CPG reviewed


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Medicine


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Psychiatry


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Pharmacy (Drug Info Center)

+16 CPG reviewed


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Ophthalmology


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Orthopedics

+1 CPG reviewed


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Otorhinolaryngology (ENT)


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Obstetrics & Gynecology

+2 CPG reviewed


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Surgery

+1 CPG reviewed


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Nursing

+3 CPG reviewed


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PCC (Family Medicine)

+6 CPG reviewed


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Anesthesiology

+1 CPG reviewed


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Emergency Medicine

+10 CPG reviewed


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Dermatology

Examples of KSUMC Clinical Practice Guideline Adaptation

& Implementation Projects

presented and/or published in International Conferences AND

National Events

The adapted CPG for Management of Diabetic Ketoacidosis in children from the Department

of Pediatrics• Presented by Dr. Sara Mohamed, Associate Professor &

Consultant of Pediatric Endocrinology & Metabolism and Head of Pediatrics CPGs Subcommittee presented in two international conferences:-1. American Endocrine Society Conference, San

Francisco, USA. CPG: challenges and opportunities in 14/6/2013 ENDO 2013 15-18/6.

2. European society of pediatric endocrinology conference, Milan, Italy in 20/9/2013 – DKA Guidelines: Saudi Experience.

Featured Poster Presentation Number: FP32-6 Poster Board Number: MON-282https://endo.confex.com/endo/2013endo/webprogram/Paper6468.html

A

DISCLOSURES: Nothing to disclose

Development and implementation of Clinical Practice Guidelines in Pediatric Endocrinology: Challenges and opportunities

Sarar Mohamed, Hala Omer, Nasir Al Jurryaan, Amir Babiker, Hessah Al-Otibi, Rana Hasanato, Shaikh Iqbal ,Mohamed Elfaki Osman, Nouf Alkhemis, Ali Abdo, Abdulrahman Al-NemriDepartment of Pediatrics & Chemistry, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia

https://endo.confex.com/endo/2013endo/webprogram/Paper6468.html

The adapted CPG for Management of Bipolar Disorder from the Department of Psychiatry

•Presented by Dr. Yasser Amer, AND Professor Lubna Al-Ansary presented in 10th International Guidelines International Network (G-I-N) Conference in San Francisco, USA in 18-21 August 2013 and presented the KSUMC CPG Program activities in the G-I-N Adaptation Working Group Meeting in SF, USA


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G-I-N 2013 San Francisco


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The Adapted CPG FOR Central Vascular Access Device (CVAD) FROM THE NURSING DEPARTMENT

Featured in the E-VAN May 2014 issue (Electronic Newsletter of AVA) by Ms Maan Ciocson.

Publication in JAVA (in progress) by the CPG Adaptation working group.

National Representation

• 15-16/5/2013: Active participation in ‘Developing Strategic Vision

for Saudi Center for Evidence-Based Health Care,

Ministry Of Health workshop, Riyadh, KSA

•KSU College of Medicine & University Hospitals Representatives

were Professor Lubna Al-Ansary, Dr. Ayman Abdo, Dr. Yasser S. Amer

and Ms. Nada Alkhamis )


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05/01/2023 CPGs Adaptation & Implementation in KSUMC: KKUH 2014

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PART I

EBM?....EBP?...CPG?

Evidence-Based Clinical Practice

GuidelinesConcepts & Definitions

Two Different Approaches to Evidence-Based Practice Clinical Practice Guidelines (CPGs)

•“Top-down” approach• Tell clinicians how to practice• Favored by health care systems

Evidence-Based Medicine (EBM)•“Bottom-up” approach• Teach clinicians how to find answers• Favored by medical educators

EBP definitionThe integration of best

research evidence with clinical expertise and patient valuesSackett et al 2000


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Monday, May 1, 2023 CPGs Implementability & Implementation - Dr. Yasser Amer

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Evidence-to-practice process


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Knowledge Translation

Implementation research

System/ Provider and Quality Improvement

Antibiotic Prophylaxis in Surgery 74

Evidence-to-Practice

Clinical Care GAP

Current Practice

Best Practice

Clinical Care GapCPGs

Decrease

Practice

variation

Informed clinical decision making

Implementation ScienceKnowledgeTranslation

Quality/

Performance

Improvement

Patient Safety/

Care &

Satisfaction

09 JAN 2014


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What is “EBM” NOT?• What we have always done !;

(not old hat or just the same old medical practice; as evidenced in wide practice variation)

• “Cookbook Medicine”!EBM specifically advocates for individualized application of evidence to patient care, not forcing patient care to conform to generalized evidence

• Only a cost-cutting trick !;it is intended to guide practitioners to provide the best, not necessarily the cheapest, care.

• Only RCTs !;(Also with best relevant evidence applicable to the situation in question)

– EBM is tracking down the best external evidence from scientific research to answer our clinical question(s)…

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Definition: (old)“Systematically developed statements to assist

practitioner and patient decisions about appropriate health care for specific clinical circumstances” (IOM 1990).

Increasing international interest in the development and implementation of CPGs.

Clinical Practice Guidelines (CPGs)

CPGs New Definition

CPGs are “Statements that include Recommendations intended to optimize patient care that are informed by a Systematic Review of evidence and an assessment of the benefits and harms of alternative care options”.Committee on Standards for Developing Trustworthy CPGs (IOM-AHRQ 2011)

Why do we n

eed

CPGs?

Rationale for CPGs•Worldwide concerns about: ▫Unexplained variations in clinical

practice▫Rising health care costs▫Exponential growth of information

• Aim of Clinical Practice Guidelines:▫To facilitate more consistent, effective and efficient

practice and improve health outcomes for patients

Who needs

CPGs?

EBCPGs: Dr. Yasser Sami Amer 82

Stakeholders (TEAM)•Physicians•Nurses•Pharmacists•Decision makers•Patients•Public

19th March 2013

How do w

e rea

ct to

CPGs?

Read

AdoptAdapt

Develop

CPGs ?

Different Options to deal with CPG

Adoption

Adaptation

Rejection

Process/ Methods

EBCPGs: Dr. Yasser Sami Amer 8719th March 2013

Adaptation of CPGsIs the systematic approach to the endorsement

and/or modification of a guideline(s) produced in one cultural and organizational setting for application in a different context. Adaptation may be used as an alternative to de novo guideline development, e.g., for customizing (an) existing guideline(s) to suit the local context.

http://www.adapte.org/http://www.g-i-n.net/

05/01/2023 89

Hospital-Wide Policy & Procedure for Hospital CPGs Adaptation

SEPT 2013

NEW


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Team - TopicTotal Number of Health Topics for CPGs from all departments

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Selecting a CPG Topic Prevalence of the condition (high volume) Patient safety concern (high risk) Under-, over-, misuse of intervention(s) Burden due to the condition Practice variation Costs of different practice options Likelihood of effectiveness of CPG Potential for improving quality of care and/or

outcomes Existence of relevant good quality CPGs

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21 KSUMC CPGs Subcommittees1. Department of Pediatrics 2. Department of Critical Care 3. Department of Psychiatry 4. Primary Care/ Family Medicine Clinics

(Ambulatory Care Services) 5. Department of Pharmacy 6. Department of Emergency Medicine 7. Department of Medicine8. Department of Orthopedic Surgery 9. Department of Otorhinolaryngology 10. Department of Ophthalmology 11. Department of Cardiac Sciences/ KFCC

(Cardiology – Cardiac Surgery) 12. Department of Surgery 13. Department of Obstetrics & Gynecology 14. Department of Dermatology 15. Department of Anesthesiology 16. Department of Laboratory Medicine &

Pathology 17. Department of Nursing

18. Department of Radiology 19. Health Education Center 20. Department of Rehabilitation Medicine21. Department of Infection Control

New (in progress)1. Department of Occupational Health & Safety2. Department of Clinical Nutrition


Health/ Clinical/ Key QuestionsPatient (& disease characteristics)

Intervention(s)

Professionals (Target users)

Outcomes (purpose of the CPGs)

Healthcare settings (& context)

19th March 2013

CPG Scope: PIPOH Model


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Health Question Tool (modif.)


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Inclusion / Exclusion CPGs Selection Criteria (6)

1. Methods of Development: Evidence-Based CPGs: (Detailed Methodology not Consensus-based CPGs (Expert opinion)

2. Author(s): Organization and Specialized Society not single authors.

3. Country: International not national CPGs.4. Date of Publication: range of year of

publications: last 5 years or less (e.g. 2010 – 2014) – except if none!

5. Language: English CPGs only6. Status: only Original source CPG (de novo

developed) rather than adapted CPGs


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CPG selection criteria Tool (new)

CPGs on the Web

CPGs on the Web

Producers Finders

Guideline Producers• Specialized societies

• National agencies NICE SIGN

Organization NameCountry

URL Producer

Finder FREE PAID

Guidelines International Network (G-I-N) Int’l http://www.g-i-n.net F √ √

World Health Organization (WHO) Int’l http://www.who.int/topics P √

National Institute for Health & Clinical Excellence (NICE) UK http://www.nice.org.uk/page.aspx?

o=ourguidance P √ √

Scottish Intercollegiate Guidelines Network (SIGN) Scotland http://www.sign.ac.uk/guidelines/

index.html P √

New Zealand Guideline Group (NZGG) NZ http://www.nzgg.org.nz P √Registered Nurses Association of Ontario (RNAO) Canada http://www.rnao.org P √

National Guidelines Clearinghouse (NGC) USA http://www.guidelines.gov F √

US National Library of Medicine, National Institutes of Health (PubMed)

USAhttp://www.ncbi.nlm.nih.gov/

pubmedOR http://www.pubmed.gov

F√

(Abstracts)

√(Full

Text)

Institute for Clinical Systems Improvement (ICSI) USA http://www.icsi.org/knowledge/ P √


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AAP CPGs


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ACP CPGs


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NKF CPGs

CPG Producers:National Agencies

NICENational Institute for Health & Clinical Excellencewww.nice.org.uk

http://www.nice.org.uk/

SIGNScottish Intercollegiate Guidelines Networkwww.sign.ac.uk

CPG Producers:National Agencies

http://www.sign.ac.uk/

RNAO Toolkit• Toolkit for

implementation of CPGs

• www.rnao.ca

http://www.rnao.ca/

CPG Finders

AHRQNational Guideline

Clearinghousewww.guidelines.gov

http://www.guidelines.gov/

Shaikh Bahamdan’s Research Chair for Evidence-Based Health Care & Knowledge Translation

Member of G-I-N since Oct. 2009Free access to International CPG Library of G-I-N

http://c.ksu.edu.sa/ebhc/en



http://ebhc.ksu.edu.sa/gin/index.html

CPG Finders

PubMedUS National Library of

MedicineNational Institutes of

Health (NIH)

EVIDENCE PYRAMID ?

120

EBCPGs: Dr. Yasser Sami Amer 12119th March 2013

Evidence Pyramid

SR

RCT

Cohort

Case control

Case series

Case report

Expert opinion

I

II

III

IV

A

B

CLeve

ls o

f Evi

denc

eG

rades of Recom

mendations

LevelEvidence

GradeRecomm.

Strength

EVIDENCE PYRAMID


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CPG-ICU-002 (VTE) 2013


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HWCPG-ENT-001 (ABRS) 2013


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HWCPG-PHARM-001 (Vanco)


How to assess of the quality of any CPG?

19th March 2013


Assess guideline quality

ADAPTE TOOL 9 AGREE II Instrument

23 items in 6 domains 7 point response scale Domain scores Recommendations

19th March 2013

AGREE II 6 DomainsDOMAINS

1 Scope & Purpose2 Stakeholder

Involvement3 Rigour of Development

(Methods)4 Clarity & Presentation5 Applicability6 Editorial Independence

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The concept of the ‘LIVING’ CPG


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End of Finalization Phase1. CPG Subcommittee submit finalized CPG draft to

Evidence Base & Research Unit, Quality Management Department for review;

2. Submit to Hospital-wide CPG Committee for review of adaptation process methodology and final approval;

3. Congratulations letter to Chairman of department4. Start dissemination and implementation in

relevant departments;5. Follow up, clinical auditing & measurement in

relevant departments;


Dissemination & Implementation

Nothing could be more frustrating than producing a CPG that is then ignored by not being disseminated

nor implemented

19th March 2013


134

PART II


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CPGsImplementation

Strategies & Tools

CPG Implementation• “The concrete activities and

interventions undertaken to turn policies into desired results“

Guidelines for clinical practice: from development to use. IOM, 1992

CPGs Practice

CPG Implementation Failure….WHY?

Extrinsic to CPG: provider-specific & care system-related

Intrinsic to CPG: ambiguity – inconsistency - incompleteness

Facilitators: QuestionsFrom your experience, what are

the most important factors that facilitate CPGs implementation?

Individual Positive attitude

Learning through small group interaction

Organizational Leadership support

Champions Team work collaboration

Environmental Professional association

support Inter-organizational collaboration networks

Facilitators

Implementability• Set of characteristics that PREDICT

the relative ease of implementation of CPG recommendations.

Implementability…….BEFORE implementation

How to Measure Implementability?

Ease and accuracy of translation of guideline advice into systems that influence care.

GLIA TOOLRichard N. Shiffman, MD, MCIS

Yale Center for Medical Informatics, Yale University

2005 - 2011


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SIGN is customizing implementation support to every CPG. Ali El-Ghorr et

al


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CPG implementation strategies

Dissemination Process (print/ e-/website)Local Clinical Champions.Awareness raising/ training activities.Networking and linking with existing

projects (e.g. Dept. Clinical Rounds, CPD/CME activities, Accreditation, etc..).

Patients as champions for change.Regular M & E (The ‘living’ CPG concept!).


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Dissemination process (1st TOOLS!!!)

• I- PRINTED MATERIAL (booklets, brochures, cards, CPG binders in some nursing stations, etc..)

• II- ELECTRONIC MATERIAL: (a) Full CPG copies (PDF files) on desktop of PCs in the following points of care:

• outpatient clinics (ambulatory)• nursing stations in the inpatient wards• nursing stations in the DEM• Pharmacy

(b) The QM website (KSU email log in)


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Local Clinical ChampionsClinical quality champions must be known within the organization & community as both promoting and delivering best practices (EBP) with their patients.Strategic leadership. The Healthcare Quality Handbook. JB. 26th Ed. 2011/2012

CPG Implementation Tools

:: Evidence to practice/ knowledge to action cycle

Monday, May 1, 2023 147

Adapt/ design CPG implementation tools available at the point of care (* MR)

TYPES1. Clinical Algorithm.2. Integrated Care/ Clinical Pathways*.3. Protocol.4. Chart Documentation/ checklists/ forms (e.g. Physician Order Sets* later

CPOE/eSIHI).5. Quick Reference Guides/ Physician Guides & Pocket Guide/Reference Cards (at-

a-glance summary of key recommendations 5 or 1-2 pages).6. Clinical audit criteria (tool)7. Quality (outcome/performance) measures8. Slide Presentation.9. Wall Poster.10.Patient Resources/ Information (health education guides).11.Foreign language Translation (Non-English, Non-Arabic).12.Implementation Tool Kits (collections of tools and/or strategies).13.Staff Training/ Competency Material.

CPGs Implementability & Implemen.tation - Dr. Yasser Amer


148

Clinical algorithm• A diagram of the guideline

recommendations presented as a step-by-step decision-tree


149

CPGs Implementability & Implementation - Dr. Yasser Amer

150

Clinical PathwaysSyns.: Integrated Care Pathways, Multidisciplinary pathways of care, Pathways of Care, Care Maps,

Collaborative Care Pathways.• Definition: structured, multidisciplinary care

plans designed to support …………………(3)1. implementation of CPGs and protocols.2. clinical management, clinical and non-clinical resource

management, clinical audit & financial management.3. detailed guidance for each stage in the management of a

patient with a specific condition over a given time period, including progress and outcomes.


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Care pathways differ from CPGs, protocols and algorithms as they are utilized by a multidisciplinary team and have a focus on the quality and care co-ordination.


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Pathways’ Four main Components:

1. Timeline.2. Categories of care or activities and

their interventions.3. Intermediate and long term outcome

criteria.4. Variance record (to allow deviations to

be documented and analyzed).

Monday, May 1, 2023 153

Benefits1. Support the introduction of EBM and use of

CPGs.2. Support clinical effectiveness, risk management

and clinical audit.3. Improve multidisciplinary communication,

teamwork and care planning.4. Can support continuity and co-ordination of care

across different clinical disciplines and sectors.5. Provide well-defined standards for care.



154

Benefits (cont’d)

6. Help reduce variations in patient care (by promoting standardization).7. Help improve clinical outcomes.8. Help improve and even reduce patient documentation.9. Support training.10. Optimize the management of resources.11. Does not override clinical judgment.


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Differences between

Clinical Algorithm Clinical Care Pathway Decision – making. Coordinating Care.

Series of questions that guide designing sequence of steps.

Goal statement that guide key elements of care, roles and sequence of activities

Generic; applicable to all patients Individualized; may be designed for individual patient (integrated care plan)

Not time-related Time-related; hours in ED, days in acute care, weeks in chronic and home care.

Staff not mentioned clearly Usually multi-disciplinary staff and should be mentioned in the care plan

Systematic actions Systematic actions


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Differences between

Clinical Algorithm Clinical Care Pathway Not outcome-related (does not

include standards or outcome of care)

Outcome-related (includes standards or outcome of care)

Only clinical processes Clinical & non-clinical processes

Maps Maps

Does not include order or priorities Includes order and priorities

Includes continuous feedback through tracking and analysing variance

Includes continuous feedback through tracking and analysing variance

No details of treatment Includes details of treatment


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Standard Order Sets/ Standing Orders

Collection of medical orders in a pre-filled ordering paper template forms or in a computerized physician/provider order entry system (CPOE) for a selected group of patients throughout the different disciplines and it is usually based on EBCPGs to standardize diagnosis and treatment.

Monday, May 1,

2023


159

Two types are currently identified in KSUMC:-1) Expert/ Consensus-based order sets: these

forms are result of the collaboration of one or more clinical departments and would require careful review and clinical expertise.

2) Evidence-Based order sets (Systematic Methodology): these forms are based on hospital adapted CPGs that were officially approved by the hospital CPGs committee (refer to HWQPP – 010)

Computerized Provider Order Entry (e-SIHI)IN PROGRESS!


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HWQPP – Standing orders development, revision & deletion (2014)

05/01/2023 161

Computerized Physician Order

Entry (CPOE)And Medication Errors!

Med. Err. & CPOE – Amer, Yasser

05/01/2023 162

Current Hospital Info. System (2 icons)


05/01/2023 163

Current Hospital IS (2 icons) (cont’d)

1. KKUH – Lab Access System2. Centricity Web –PACS

Not comprehensive HIS or EMR!Not supporting CPOE!

Physicians order Ix in “paper forms” and Lab & Radio staff encode results.

Physicians order Rx in “paper” physician orders.Unclear illegible hand-writing of doctors.Paper request forms sometimes get lost or

damaged.Patient safety implications.



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05/01/2023 165Med. Err. & CPOE – Amer, Yasser

With or without Clinical Decision Support (CDS)


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05/01/2023 167

SOLUTION• New HIS (e-SIHI) project supports CPOE.• Physician Build team assigned to build CPOEs

in collaboration with Lab., Pharm & Nursing.• CPOEs (order sets) based on hospital

approved adapted Evidence-based CPGs.


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05/01/2023 Med. Err. & CPOE – Amer, Yasser 169

Expected benefits of HIS w. CPOE

05/01/2023 170

Expected benefits of HIS with CPOE

1. Reduce Medication Errors (patient safety)2. Serve as a reminder for busy clinicians (education)3. Clinical decision support during data entry

(Evidence-Based CPGs)4. Reduce time (save seconds/ mouse clicks): more

time spent with patients??5. Improve tracking & record keeping6. Improve communication & integration of patient

information.



171

Protocol• What is the difference between a "clinical guideline," "practice

parameter," and "standard"?• The phrases "protocol," "practice parameter," "pathway,"

"standard," "consensus statement," etc., are used in many different contexts and may not necessarily be a clinical practice guideline.

• Clinical protocols are more specific than CPGs, defined in greater detail; provide a comprehensive set of rigid criteria outlining the management steps for a single clinical condition or aspect of organization"


172

Audit Criteria/ indicators & Quality Measures

• Systematically developed statements that can be used to assess the appropriateness of specific healthcare decisions, services, structure, performance, and outcomes


173

Some Examples of currently monitored indicators for year 2013-14

• Structure Indicators (2)• Clinical documentation• Performance Indicators (4)• Length of stay• Outcome indicators (18)• Medication error• Adverse drug reaction• Mortality rate• Morbidity rate•Other clinical audit criteria have been identified special to some CPGs topics


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Patient information


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Launching CPG pilot implementation Timeframe: ……… Months

Starting date: …./ …../ ……… Monitoring & Evaluation Checkpoint #1:

• TEAM (Taskforce) Essentially everyone is a

• “CPG Champion” Physicians Nurses Pharmacists Technicians Allied HC professionals Others


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Identify & Prioritize Key recommendations & outcomes

• # 1 …………………………………………………………………………………………………………….• # 2 ……………………………………………………………………………………………………………..• # 3

……………………………………………………………………………………………………………….

Identify Implementation Barriers

I. Who? Key stakeholder analysis [each…….Influence × Support: HIGH/LOW]

II. Other barriers? (e.g. equipment, medications, workflows,….etc.)

CPGs Adaptation & Implementation in KSUMC: KAUH 2014

177

Action plan• Timeframe: (e.g. 3 Mo., 6 Mo., 1 Yr.)• Identify targets:

• Primary: e.g. patients/clients• Secondary: e.g. Doctors, Nurses,…..etc.Strategies Short term plan Long term plan

FEB10/2

MAR APR15/4

MAY JUN JUL AUG SEP OCT

NOV DEC

• Prepare/ finalize imp. Tools (paper & E-) Final

Survey 2nd Cycle of AC

• Awareness campaignTop management/ Dept. Chair + clinical championsIT ( screens/desktops)

• Education campaign (target users, clients and carers)

• Dissemination (Formats: paper/ E-)

• Other Implementation initiatives

• System of care (change needed)

• Evaluation: M & E (Clinical Audit)

• Sustainability


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PART III

05/01/2023 CPGs Adaptation & Implementation in KSUMC: 2014

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2nd Accreditation Canada Cycle 2014

Together We did it !

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Thank YOU all for listening

Contact Information: Dr. Yasser Sami AmerEmails: [email protected]; [email protected]: +966-50-857-7246, +966-51-525-2439Office: +966-11-46-91341

mailto:[email protected]

mailto:[email protected]