IOM Workshop on Standards for Clinical Practice Guidelines

January 11, 2010Presentation to Committee on Standards for

Developing Trustworthy CPGs

Karen KellyThomas, PhD, RN, FAANCEO

National Association of Pediatric Nurse Practitioners (NAPNAP)

Scope of presentation/perspective

NAPNAP Healthy Eating and Activity Together (HEATsm) Program and CPG

NAPNAP Keep Yourself/Your Children Safe and Secure (KYSS sm) Program and outcomes

AWHONN RBP Program and projects1996-2003Reference List for 4 projects

Research and Development in 4 hospitals1975-1996

Bernadette Melnyk, PhD, RN, CPNP/NPP - ASUEvidence-based Practice in Nursing and Healthcare

Melnyk et al Seven Steps Step 0 - Cultivate a spirit of inquiry Step 1 - Ask clinical question in PICOT format (population, area

of interest, comparison intervention or group, outcome, time) Step 2 - Search for the best evidence Step 3 - Critically appraise the evidence Step 4 – Integrate the evidence with clinical expertise and

patient preferences and values Step 5 – Evaluate the outcomes of the practice decisions or

changes based on evidence Step 6 – Disseminate the result

Other models in use i.e. Titler/Iowa; Stevens/UTHSA

The biggest challenges facing developers today

Confessions of a contingency theory based and pragmatic CEO

Finding right people, time and money; learning up Determining clinical discipline and practice specificity Deciding to develop, adopt, endorse, adapt or not Developing trust, Recognizing competition and need for ownership Measuring uptake and claiming results of implementation Branding, creative packaging and access for clinician users Participating in the relentless quest for sustainability or

barbecuing a sacred cow Managing fear of the unknown and interfaces necessary

EHR, clinical decision support systems Translation of comparative effective research Developing CPGs that consider availability of health

information technology and payment modes

Within our known healthcare universe, environment, systems, and contexts within

Looming EHRs ‘meaningfully used’ Principles of transparency Knowledge of performance measures Knowledge of gaps and limitations Political, science and human communities The activities as forethought Within knowledge that stopping is harder than

starting Within core of truth of best practice universe

Yet knowing life feels more like a gyroscope teetering toward more knowledge and stronger trust

Never trust the teller. Trust the tale. (D.H. Lawrence)

What do we do when scientific evidence is absent or poor?

Admit it and move ahead

Reconciling Differences

Agree with Pawlson (2009) definition: CPGs are evidence based statements of optimal (‘best’) practices

Value IOM (1990) definition: Clinical practice guidelines are systematically developed statements to assist the practitioner and patient decisions about appropriate health care for specific clinical circumstances

Use a systematic process Empower science teams to decide Trust spirit of volunteer commitment Trust clinical judgment of expert and experienced

clinicians (and intuition…with recognition)

Reconciling disagreements

Select a schema to appraise evidence quality and stick to it

Avoid every impulse to create another schema or scoring method (82+ is enough!)

Encourage lusty debate that informs all team members and others

I think we may safely trust a good deal more than we do

(Emerson)

How we accommodate guidelines to subgroups whose treatment outcomes may differ from ‘average’ patient

Pediatric population as primary group ‘Accommodation’ as standard in well child

visits, anticipatory guidance, and EPSDT Body of knowledge about children with special

healthcare needs AHRQ draft Core Set of Child Healthcare

Quality Measures for Medicaid and CHIP Programs – NAPNAP involvement and public comments (March1, 2010)

Other important challenges Child-focused interdisciplinary guidelines that identify

contributions of different providers providing same care Recognition of child’s healthcare home and multiple

primary healthcare providers’ scope of practice Recognition of parent as primary health and care

provider Quest for integrated guidelines – provider inclusive

ASLAAAP/AAFPADAAnd who/how many others

CPGs that work in urban, suburban and rural settings Culturally appropriate CPGs

NAPNAP recommendations for CPG Guideline Panel Membership

• Must be Provider inclusive • Balance membership of

diverse clinical expertsMethodologistsparent/consumers

Consider including an interpretive-hermeneutic researcher

Managing ‘nattering nabobs of negativism’

Safire for Agnew

Consider

Methods for selecting recommendations to apply CQI measures – identified as part of process, tag and prioritize, challenge the best testers with incentives, continuously define clinical effectiveness measures

Available rating/assessment tools – rank those available, recognize patterns, be pragmatic, polish the ‘tarnished silver’, don’t throw babe out with bathwater

Keep using the words credible and trust - it goes both and all ways

Development of economics of it all and true stakeholders of it all

Administrative, accreditation, or legal approaches that might improve the quality of CPGs

Create and disseminate a briefing for stakeholder administrators that will inform

Promote AHRQ Guideline Clearing House If GLIA (Implementability Assessment) has validity and

reliability, push out to associations who develop guidelines with care to include developers of a few and developers of many of diverse healthcare providers

Disseminate AVUL (ambiguous, vague, underspecified language) as strategy for guideline developers

Reduce the size of the ‘black box’ of electronic guideline knowledge representation

Do not develop an accreditation process for a few; if developed process must be applicable to all developers

Harmonizing and converging guidelines

Bring diverse groups together then send them out Expand opportunities for professional societies to develop

and become PBRNs as underframe Call the ‘best of the best’ to action Be careful what you ask for

Other characteristics of guideline standards that are important

I may not be perfect, but parts of me are excellent

(Ashleigh Brilliant, 1964)

Promoting greater use of guidelines

Research utilization, knowledge utilization, evidence based practice (EBP research), research-based practice, translation research…and on

Use decades of acquired knowledge to create more champion opportunities for more developers to come together then push out

Go forth and disseminate Pay attention to the need for the proverbial resources Anyone using BridgeWiz (Shiffman, Nov 9, 2009 mtg

presentation)