Guideline “Implementability” Appraisal or if you write it will they use it?

Guideline “Implementability” Appraisal Guideline “Implementability” Appraisal or if you write it will they use it? or if you write it will they use it?

Jean SlutskyJean SlutskyDirector, Center for Outcomes and EvidenceDirector, Center for Outcomes and Evidence

September 4, 2008September 4, 2008

OverviewOverview

DefinitionsDefinitions PitfallsPitfalls SolutionsSolutions ResourcesResources

Implementation vs. Implementation vs. ImplementabilityImplementability

Design and deployment Design and deployment of systems, tools, and of systems, tools, and strategies designed to strategies designed to influence clinicians’ influence clinicians’ behavior toward behavior toward adherence to guideline adherence to guideline recommendationsrecommendations

Measurement: changes Measurement: changes in the structure, in the structure, process, and outcomes process, and outcomes of careof care

Source: Rick ShiffmanSource: Rick Shiffman

Characteristics that Characteristics that predict the relative ease predict the relative ease of implementation of of implementation of guideline knowledgeguideline knowledge

Measurement: ease of Measurement: ease of accuracy of accuracy of transformation of transformation of recommendations of recommendations of systems, tools, and systems, tools, and strategies that influence strategies that influence care; prediction of care; prediction of barriersbarriers

PrecisionPrecision

The tension exists in The tension exists in the uncertainty that the uncertainty that resides in the resides in the swampland known swampland known as the evidence gap as the evidence gap and the need to be and the need to be exact to assist exact to assist implementationimplementation

How do guideline developers How do guideline developers deal with uncertainty?deal with uncertainty?

They unintentionally They unintentionally (or intentionally?) (or intentionally?) make make recommendations that recommendations that are vague or are vague or impreciseimprecise– Periodicity “as Periodicity “as

needed” “routinely” “as needed” “routinely” “as indicated”indicated”

– Importance “as Importance “as appropriate”appropriate”

The consequences of The consequences of imprecisionimprecision

It leads to variability because everyone It leads to variability because everyone decides what “as needed” meansdecides what “as needed” means

Hard to develop organizational systems Hard to develop organizational systems to enhance guideline use when to enhance guideline use when statements are hard to interpretstatements are hard to interpret

It yields the authority of the guideline It yields the authority of the guideline panel to the individual implementerpanel to the individual implementer

The Guideline Implementability The Guideline Implementability Appraisal (GLIA)Appraisal (GLIA)

The objective of GLIA is to provide a tool The objective of GLIA is to provide a tool for the appraisal of the implementability for the appraisal of the implementability of clinical guidelines. of clinical guidelines.

GlobalGlobal– Precisely under what conditions to do Precisely under what conditions to do

something something

Decidability Decidability – Precisely under what conditions to do Precisely under what conditions to do

something something

The Guideline Implementability The Guideline Implementability Appraisal (GLIA)Appraisal (GLIA)

Executability Executability – Exactly what to do under the Exactly what to do under the

circumstances defined circumstances defined Effect On Process Of CareEffect On Process Of Care

– Degree to which the recommendation Degree to which the recommendation impacts upon the usual workflow of a care impacts upon the usual workflow of a care setting setting

Presentation & FormattingPresentation & Formatting– Degree to which the recommendation is Degree to which the recommendation is

easily recognizable and succinct easily recognizable and succinct

The Guideline Implementability The Guideline Implementability Appraisal (GLIA)Appraisal (GLIA)

Measurable OutcomesMeasurable Outcomes– Degree to which the guideline identifies Degree to which the guideline identifies

markers or endpoints to track the effects of markers or endpoints to track the effects of implementation of this recommendation implementation of this recommendation

Apparent Validity Apparent Validity – Degree to which the recommendation Degree to which the recommendation

reflects the intent of the developer and the reflects the intent of the developer and the strength of the evidence strength of the evidence

The Guideline Implementability The Guideline Implementability Appraisal (GLIA)Appraisal (GLIA)

Novelty/Innovation Novelty/Innovation – Degree to which the recommendation Degree to which the recommendation

proposes behaviors considered proposes behaviors considered unconventional by clinicians or patients unconventional by clinicians or patients

The Guideline Implementability The Guideline Implementability Appraisal (GLIA)Appraisal (GLIA)

Flexibility Flexibility – Degree to which a recommendation Degree to which a recommendation

permits interpretation and allows for permits interpretation and allows for alternatives in its execution alternatives in its execution

Computability Computability – Ease with which a recommendation can be Ease with which a recommendation can be

operationalized in an electronic information operationalized in an electronic information system system

BMC Medical Informatics and Decision Making 2005, 5:23

http://gem.med.yale.edu/glia/login.htm

ResourcesResources

http://gem.med.yale.edu/cogs/links.dohttp://gem.med.yale.edu/cogs/links.do http://gem.med.yale.edu/glia/login.htmhttp://gem.med.yale.edu/glia/login.htm http://gem.med.yale.edu/default.htmhttp://gem.med.yale.edu/default.htm www.guideline.govwww.guideline.gov www.g-i-n.netwww.g-i-n.net