ORGANIZATIONAL AND CLINICAL FACTORS INFLUENCING
USE OF CLINICAL PRACTICE GUIDELINES
Subject:
Progress Report Summary
Date:
05/04/01
Submitted to:
The Center for Health Management Research
Department of Health Services
Room H660, Box 357660
Seattle, WA 98195-7660
Investigators:
Tamara T. Stone, Ph.D., University of Missouri-Columbia
Seema S. Sonnad, Ph.D., University of Michigan
Sharon B. Schweikhart, Ph.D., The Ohio State University
PROGRESS REPORT SUMMARY
The following is a narrative of the progress on the above stated project, funded by the Center for Health
Management Research (CHMR), for the seven month time period 10/01/00 through 04/30/00. The
comments and advice provided by the Project Advisory Committee is greatly appreciated and has been
helpful in advancing this project.
Project Advisory Committee Membership as of 04/30/01:
Banner Health Arizona
Mercy Health Services
Summa Health System
Virginia Mason Medical Center
Mary Ellen Dirlam, MD
Louise Milobowski, RN, MSN
Edward Schneir, MD
Nancy Neil, PhD
Problem / Issue to be Addressed
Although current literature supports the use of evidence-based clinical practice guidelines (CPGs), there is
limited research concerning institutional and operational issues that may be inhibiting effective CPG
implementation. The objective of our research is to increase understanding of clinical practice patterns by
in integrated systems by 1) identifying the role of system integration in guideline implementation processes
and 2) identifying physician preferences for CPG accessibility, learning strategies, content, and format in an
effort to increase guideline utilization.
Significance / Benefit to Sponsors
 Enhance understanding of how integrated health systems develop and implement CPGs and how
health system integration may serve to influence the success in achieving improvements in controlling
practice variation and costs while maintaining quality.
 Provide a more thorough understanding of the attributes of guidelines and supporting implementation
processes that foster physician adoption of and adherence to CPGs.
 Provide a clearer understanding of physician preferences for guideline implementation that are
effective in different clinical environments to enable health care systems to design processes tailored to
meet physician needs.
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
Page 1 of 18
Approach / Objectives
 Identify how organizations select topics for the application of CPGs
 Determine how system membership affects the guideline implementation process
 Document how guidelines are implemented in various clinical settings
 Examine the goals of guidelines in different systems and their impact on utilization
 Identify physician preferences for guideline implementation
Methods / Data Sources
 Telephone survey of physicians using acute myocardial infarction and pediatric asthma CPGs
 Semi-structured interviews with physicians and administrative leaders involved with guideline
implementation
 Collection of physician and organization characteristic information
 Collection of corporate documentation regarding guideline implementation practices
 Paired sample t-test and Tukey’s method of multiple comparison to identify relative ranking of physician
preferences for guideline implementation
 Content analysis to discover relationships between the use and implementation of CPGs
Products
 Summary report identifying system characteristics and general physician preferences that foster
effective CPG implementation
 Detail report, for each participating corporate member, identifying system characteristics and physician
preferences for CPG implementation
 Recommendations for modifying CPG implementation
 Empirically tested instrument to measure physician preferences for CPG implementation
 Set of testable hypothesis concerning the role of integrated systems in guideline implementation
 Publications in professional journals
Phase I – Quantitative Methods Progress (PI: Tamara T. Stone, Ph.D.)
All physician interviews are complete. Any responses received from physicians after 05/31/01 will not be
included in the final analysis. We do not anticipate many additional responses during the month of May, so
results included in this report should very closely approximate the final study findings.
The response rates for Phase I physician interviews are as follow:
Response Rate - Overall (Pediatric Asthma & AMI)
Total
Peds
FP
Original List
730
113
260
No longer w/ System
24
10
5
Ineligible
1
1
0
Total Sample
705
102
255
Declined
49
4
24
Could not contact
160
8
52
Responses
496
90
179
Response Rate
70.35% 88.24% 70.20%
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
IM
Cardiology
237
124
8
1
0
0
229
123
6
15
50
50
173
58
75.55% 47.15%
Page 2 of 18
Response Rate - Virginia Mason Medical Center (Pediatric Asthma only)
Total
Peds
FP
IM
Cardiology
Original List
64
31
33
No longer w/ VMMC
2
2
0
Ineligible
1
1
0
Total Sample
61
28
33
Declined
2
0
2
Could not contact
6
1
5
Responses
53
27
26
Response Rate
86.89% 96.43% 78.79%
Response Rate - Banner Health System (AMI only)
Total
Peds
FP
Original List
89
4
No longer w/ Banner
1
0
Ineligible
0
0
Total Sample
88
4
Declined
10
0
Could not contact
26
0
Responses
52
4
Response Rate
59.09%
100.00%
Response Rate - Summa Health System (AMI only)
Total
Peds
FP
Original List
157
65
No longer w/ Summa
1
0
Ineligible
0
0
Total Sample
156
65
Declined
15
6
Could not contact
56
24
Responses
85
35
Response Rate
54.49%
53.85%
IM
Cardiology
42
47
0
1
0
0
42
46
0
10
4
22
38
14
90.48% 30.43%
IM
Cardiology
79
13
1
0
0
0
78
13
5
4
25
7
48
2
61.54% 15.38%
Response Rate - Trinity Health System (Pediatric Asthma/AMI)
Total
Peds
FP
IM
Cardiology
Original List
420
82
158
116
64
No longer w/ Trinity
20
8
5
7
0
Ineligible
0
0
0
0
0
Total Sample
400
74
153
109
64
Declined
22
4
16
1
1
Could not contact
72
7
23
21
21
Responses
306
63
114
87
42
Response Rate
76.50% 85.14% 74.51% 79.82% 65.63%
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
Page 3 of 18
The primary objective of Phase I of this study was to provide a clearer understanding of physician
preferences for guideline implementation that are effective in different clinical environments to enable
health systems to design processes tailored to meet physician needs. Specifically, we evaluated the
implementation of two guidelines (Pediatric Asthma and Acute Myocardial Infarction (AMI)) in four health
systems (Virginia Mason Medical Center – Pediatric Asthma only, Banner Health System – AMI only,
Summa Health System – AMI only, and Trinity Health System – Pediatric Asthma and AMI).
Five discrete hypotheses were tested to determine physician preferences for guideline placement, learning
strategies to encourage physician use of guidelines, guideline content, guideline format, and the type of
medical evidence physicians find most useful when treating patients. The specific hypotheses are as
follow:
H1: Specific locations for guideline placement (on front of patient chart, at nurses’ station, in progress
notes, on hospital/clinic website, in computerized medical record, at patient bedside/examination
room, pocket card, palm pilot) are more useful to physicians at the time of treatment.
H2: Specific learning strategies (discussions with colleagues, reminder notes/stickers on front of patient
chart, verbal reminder from nurse, continuing medical education, departmental memos, verbal
reminder from patient, electronic physician newsletter, clinical path reminder) are more effective in
encouraging CPG use by physicians.
H3: Specific content areas (mild/moderate severity treatment, immediate treatment flow, severity scoring
system, panic thresholds, discharge criteria, strategies to minimize re-admits/encourage selfmanagement, references) are required by physicians in order to maximize the usefulness of CPGs at
the time of treatment.
H4: Specific guideline formats (algorithm, pre-printed orders, check sheet, flowchart/flow diagram, decision
tree, computerized medical record, disease/illness specific pamphlet, comprehensive medical book,
clinical/care pathway, order sets/templates, expert system, interactive computerized aid/QMR) are
more useful to physicians at the time of treatment.
H5: Specific types of medical evidence (independent original research, meta-analyses, randomized
controlled trials, expert consensus, case studies, locally developed study samples, nationally
representative study samples) are required by physicians in order to maximize the usefulness of
CPGs at the time of treatment.
Paired sample t-tests and Tukey's Method of Multiple Comparisons were used to test whether the
operational flow of the outpatient Pediatric Asthma and inpatient AMI guidelines supported implementation.
Paired sample t-tests are useful when comparing the means of two variables that are related or drawn from
the same population. In this study the variables were related because responses were provided by a
closed sample of study participants responding to a common set of interview questions. Paired sample ttests were used to compare group means (e.g., algorithm vs. pre-printed orders, etc.) within each section of
the interview at  = 0.05 to determine whether significant differences exist in physician preferences
regarding the operational issues of CPG implementation. For each group of statistically different means, a
secondary analysis using Tukey's Method of Multiple Comparisons was applied using a family confidence
coefficient of 95%. Tukey's method calculates all pairwise comparisons of factor level means to determine
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
Page 4 of 18
whether the difference between the pairwise means is statistically significant. The results of the Tukey
method may then provide a relative ranking of physician preferences within a given operational issue (e.g.,
relative ranking of format preference).
Basic descriptive statistics and relative rankings of physician preferences for the total study sample, as well
as for each study system, are described in the tables that follow. The study sample included interviews with
496 physicians. Sixty-seven of the respondents were residents, 404 were attending physicians, and 25
physicians chose not to respond to the question. On average, the physicians surveyed indicated that they
use guidelines a few times per week to once per day. In addition, the physicians were somewhat satisfied
to very satisfied with implementation of the guideline. One-way analysis of variance revealed that
responses from faculty physicians did not differ from those provided by residents.
Ranking of Physician Preferences for Guideline Implementation -- All Systems/All Physicians
SECTION I
Guideline Placement
Mean
Std.
Dev.
No
Preference
n
%
Slight
Preference
n
%
Moderate
Preference
n
%
Strong
Preference
n
%
On front of patient chart
2.86
1.15
114
20.1
70
12.3
154
27.1
218
38.4
Palm pilot
2.44
1.23
184
32.4
90
15.8
106
18.7
158
27.8
In progress notes
2.40
1.08
150
26.4
130
22.9
168
29.6
102
18.0
Computerized medical record
2.33
1.23
208
36.6
86
15.1
108
19.0
138
24.3
At nurses' station *
2.28
1.11
186
32.7
120
21.1
146
25.7
96
16.9
Pocket card *
2.25
1.17
208
36.6
110
19.4
114
20.1
116
20.4
At patient bedside/in examination room
1.89
1.00
262
46.1
126
22.2
114
20.1
44
7.7
On hospital/clinic website
1.82
1.07
302
53.2
102
18.0
78
13.7
64
11.3
* statistically equal @ p = 0.05
SECTION II
Learning Strategies
1 = No Preference, 2 = Slight Preference, 3 = Moderate Preference, 4 = Strong Preference
Mean
Std.
Dev.
No
Preference
n
%
Slight
Preference
n
%
Moderate
Preference
n
%
Strong
Preference
n
%
Discussions with colleagues *
3.31
2.59
20
3.5
66
11.6
262
46.1
194
34.2
Continuing medical education *
3.22
0.81
20
3.5
74
13.0
220
38.7
232
40.8
Reminder notes/stickers on front of chart **
2.74
0.94
64
11.3
138
24.3
218
38.4
124
21.8
Clinical path reminder **
2.62
0.95
80
14.1
140
24.6
218
38.4
98
17.3
Verbal reminder from nurse
2.45
1.00
126
22.2
124
21.8
220
38.7
76
13.4
Verbal reminder from patient ***
2.26
1.10
186
32.7
118
20.8
148
26.1
88
15.5
Departmental memos ***
2.17
0.88
140
24.6
198
34.9
174
30.6
30
5.3
Electronic physician newsletter
2.05
0.83
152
26.8
234
41.2
134
23.6
22
3.9
*, **, *** statistically equal @ p = 0.05
SECTION III
Guideline Content
1 = No Preference, 2 = Slight Preference, 3 = Moderate Preference, 4 = Strong Preference
Mean
Std.
Dev.
Not at all
Useful
n
Not Very
Useful
n
%
Somewhat
Useful
n
%
%
Extremely
Useful
n
%
Strategies to minimize re-admits
3.23
0.81
18
3.2
72
12.7
214
37.7
228
40.1
Immediate treatment flow
3.17
0.81
28
4.9
50
8.8
254
44.7
196
34.5
Discharge criteria
3.10
0.76
20
3.5
32
5.6
220
38.7
110
19.4
Panic thresholds *
3.01
0.91
38
6.7
100
17.6
206
36.3
180
31.7
mild/moderate severity treatment *
2.98
0.82
30
5.3
88
15.5
266
46.8
140
24.6
Severity scoring system
2.85
0.90
48
8.5
116
20.4
236
41.5
132
23.2
References
2.54
0.93
78
13.7
170
29.9
196
34.2
84
14.8
* statistically equal @ p = 0.05
1 = Not at all Useful, 2 = Not Very Useful, 3 = Somewhat Useful, 4 = Extremely Useful
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
Page 5 of 18
Ranking of Physician Preferences for Guideline Implementation--All Systems/All Physicians (cont)
SECTION IV
Guideline Format
Mean
Std.
Dev.
Not at all
Effective
n
Not Very
Effective
n
%
Somewhat
Effective
n
%
%
Extremely
Effective
n
%
Flowchart/flow diagram *
3.01
0.82
30
5.3
94
16.5
270
47.5
158
27.8
Algorithm *
3.00
0.86
36
6.3
94
16.5
258
45.4
168
29.6
Pre-printed orders *
2.92
0.90
46
8.1
108
19.0
242
42.6
154
27.1
Check sheet **
2.76
0.86
48
8.5
140
24.6
258
45.4
106
18.7
Decision tree **
2.71
0.85
52
9.2
142
25.0
266
46.8
88
15.5
Order sets/templates
2.68
0.90
61
10.9
146
25.7
238
41.9
96
16.9
Clinical/care pathway
2.59
0.86
68
12.0
152
26.8
262
46.1
66
11.6
Computerized medical record
2.45
1.09
136
23.9
150
26.4
138
24.3
122
21.5
Interactive, computerized aid/QMR
2.37
0.97
124
21.8
152
26.8
196
34.5
62
10.9
Expert system ***
2.27
0.96
128
22.5
176
31.0
152
26.8
58
10.2
Disease/illness specific pamphlet ***
2.16
0.92
146
25.7
220
38.7
132
23.9
48
8.5
Comprehensive medical book
1.95
0.88
194
34.2
216
38.0
102
18.0
32
5.6
*, **, *** statistically equal @ p = 0.05
SECTION V
Type of Evidence
1 = Not at all Effective, 2 = Not Very Effective, 3 = Somewhat Effective, 4 = Extremely Effective
Mean
Std.
Dev.
Not at all
Useful
n
Not Very
Useful
n
%
Somewhat
Useful
n
%
%
Extremely
Useful
n
%
Randomized controlled trials
3.57
0.66
12
2.1
18
3.2
166
29.2
358
63.0
Expert consensus
3.03
0.86
38
6.7
84
14.8
260
45.8
174
30.6
Independent original research
2.98
0.94
42
7.4
120
21.1
192
33.8
194
34.2
Meta-analyses
2.96
0.81
30
5.3
102
18.0
278
48.9
140
24.6
Nationally representative study sample
2.84
0.90
50
8.8
124
21.8
246
43.3
134
23.6
Locally developed study sample
2.24
0.79
100
17.6
246
43.3
182
32.0
24
4.2
2.12
0.87
142
25.0
236
41.5
138
24.3
36
6.3
Case studies
* statistically equal @ p = 0.05
1 = Not at all Useful, 2 = Not Very Useful, 3 = Somewhat Useful, 4 = Extremely Useful
The table above shows physician preferences for guideline implementation for all systems and all physician
specialties, inclusive. Physicians in general prefer guidelines to be placed on the front of the patient chart,
on their personal palm pilots, or in the progress notes. They do not favor guideline placement at the patient
bedside/in the examination room or on the hospital/clinic website. Physicians are most encouraged to use
guidelines through discussions with colleagues and through continuing medical education. Departmental
memos and electronic newsletters are least effective in encouraging guideline utilization. Physicians find
strategies to minimize re-admits/encourage self-management and immediate treatment flows to be the
most useful information included in guidelines, and that references while important are not necessary at the
time of patient treatment. Physicians prefer guidelines in the form of flowcharts/flow diagrams, algorithms,
and pre-printed orders, while the common disease/illness specific pamphlets and comprehensive medical
books are not useful formats at the time of patient treatment. Consistently through all systems, physicians
indicated that randomized controlled trials are the most persuasive medical evidence that could be included
in guidelines and that locally developed study samples and case studies generally do not sway their
treatment strategies.
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
Page 6 of 18
Ranking of Physician Preferences for Guideline Implementation -- Virginia Mason
SECTION I
Guideline Placement
Mean
Std.
Dev.
No
Preference
n
%
Slight
Preference
n
%
Moderate
Preference
n
%
Strong
Preference
n
%
At patient bedside/in examination room
2.68
1.09
10
18.9
12
22.6
16
30.2
15
28.3
Computerized medical record
2.55
1.26
17
32.1
8
15.1
10
18.9
18
34.0
On front of patient chart *
2.34
1.21
20
37.7
7
13.2
14
26.4
12
22.6
Palm pilot *
2.32
1.25
21
39.6
8
15.1
10
18.9
14
26.4
At nurses' station *
2.30
1.12
17
32.1
13
24.5
13
24.5
10
18.9
In progress notes *
2.28
1.13
18
34.0
12
22.6
13
24.5
10
18.9
On hospital/clinic website *
2.28
1.20
20
37.7
10
18.9
11
20.8
12
22.6
Pocket card
2.02
2.02
24
45.3
10
18.9
13
24.5
6
11.3
* statistically equal @ p = 0.05
SECTION II
Learning Strategies
1 = No Preference, 2 = Slight Preference, 3 = Moderate Preference, 4 = Strong Preference
Mean
Std.
Dev.
No
Preference
n
%
Slight
Preference
n
%
Moderate
Preference
n
%
Strong
Preference
n
%
Continuing medical education
3.38
0.71
0
0.0
7
13.2
19
35.8
27
50.9
Discussions with colleagues *
3.25
0.81
2
3.8
6
11.3
22
41.5
23
43.4
Verbal reminder from patient *
3.08
0.98
5
9.4
8
151.0
18
34.0
22
41.5
Clinical path reminder
2.94
0.94
3
5.7
15
28.3
16
30.2
18
34.0
Verbal reminder from nurse
2.68
0.94
8
15.1
10
18.9
26
49.1
9
17.0
Reminder notes/stickers on chart
2.55
0.95
7
13.2
20
37.7
16
30.2
10
18.9
Departmental memos **
2.13
0.81
14
26.4
18
34.0
21
39.6
0
0.0
Electronic physician newsletter **
2.13
0.79
9
17.0
32
60.4
8
15.1
4
7.5
*, ** statistically equal @ p = 0.05
SECTION III
Guideline Content
1 = No Preference, 2 = Slight Preference, 3 = Moderate Preference, 4 = Strong Preference
Mean
Std.
Dev.
Not at all
Useful
n
Not Very
Useful
n
%
Somewhat
Useful
n
%
%
Extremely
Useful
n
%
Strategies to encourage self-manage
3.64
0.56
0
0.0
2
3.8
15
28.3
36
67.9
mild/moderate severity treatment
3.26
0.88
5
9.4
0
0.0
24
45.3
24
45.3
Panic thresholds
3.15
0.89
3
5.7
8
15.1
19
35.8
22
41.5
Immediate treatment flow
3.02
0.96
6
11.3
5
9.4
23
43.4
18
34.0
Severity scoring system
2.87
0.94
5
9.4
12
22.6
21
39.6
15
28.3
References
2.62
0.86
4
7.5
21
39.6
19
35.8
9
17.0
1 = Not at all Useful, 2 = Not Very Useful, 3 = Somewhat Useful, 4 = Extremely Useful
SECTION IV
Guideline Format
Mean
Std.
Dev.
Not at all
Effective
n
Not Very
Effective
n
%
%
Somewhat
Effective
n
%
Extremely
Effective
n
%
Flowchart/flow diagram
3.13
0.73
1
1.9
8
15.1
27
50.9
17
32.1
Algorithm
3.09
0.77
1
1.9
10
18.9
25
47.2
17
32.1
Computerized medical record
2.96
1.00
5
9.4
12
22.6
16
30.2
20
37.7
Decision tree
2.81
0.79
3
5.7
13
24.5
28
52.8
9
17.0
Check sheet
2.77
0.82
3
5.7
16
30.2
24
45.3
10
18.9
Clinical/care pathway *
2.72
0.77
4
7.5
13
24.5
30
56.6
6
11.3
Interactive, computerized aid/QMR *
2.71
0.94
7
13.2
11
20.8
24
45.3
10
18.9
Pre-printed orders *
2.70
0.82
4
7.5
16
30.2
25
47.2
8
15.1
Expert system
2.62
1.01
8
15.1
14
26.4
17
32.1
11
20.8
Order sets/templates
2.51
0.91
8
15.1
17
32.1
21
39.6
7
13.2
Disease/illness specific pamphlet
2.32
1.00
12
22.6
20
37.7
13
24.5
8
15.1
1.92
0.83
17
32.1
26
49.1
7
13.2
3
5.7
Comprehensive medical book
* statistically equal @ p = 0.05
1 = Not at all Effective, 2 = Not Very Effective, 3 = Somewhat Effective, 4 = Extremely Effective
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
Page 7 of 18
Ranking of Physician Preferences for Guideline Implementation -- Virginia Mason (cont.)
SECTION V
Type of Evidence
Mean
Std.
Dev.
Not at all
Useful
n
Not Very
Useful
n
%
Somewhat
Useful
n
%
%
Extremely
Useful
n
%
Randomized controlled trial
3.74
0.45
0
0.0
0
0.0
14
26.4
39
73.6
Meta-analyses *
3.19
0.76
1
1.9
8
15.1
24
45.3
20
37.7
Independent original research *
3.09
0.93
4
7.5
8
15.1
20
37.7
21
39.6
Nationally representative study sample *
2.94
0.89
4
7.5
10
18.9
24
45.3
15
28.3
Expert consensus *
2.91
1.01
6
11.3
11
20.8
18
34.0
18
34.0
Locally developed study sample
2.36
0.76
7
13.2
22
41.5
22
41.5
2
3.8
Case studies
2.00
0.85
17
32.1
21
39.6
13
24.5
2
3.8
* statistically equal @ p = 0.05
1 = Not at all Useful, 2 = Not Very Useful, 3 = Somewhat Useful, 4 = Extremely Useful
The table above shows physician preferences for guideline implementation for Virginia Mason’s Pediatric
Asthma guideline. Contrary to the general findings, VM physicians prefer to have guidelines placed in the
patient examination room or on a computerized medical record, while they do not favor guideline pocket
cards. VM physicians are most encouraged to use guidelines through continuing medical education,
discussions with colleagues, and are persuaded by verbal reminders from patients. Departmental memos
and electronic newsletters are least effective in encouraging guideline utilization. VM physicians find
strategies to encourage self-management to be the most useful information included in guidelines, and that
references while important are not necessary at the time of patient treatment. VM physicians prefer
guidelines in the form of flowcharts/flow diagrams or algorithms, while the common disease/illness specific
pamphlets and comprehensive medical books are not useful formats at the time of patient treatment. VM
physicians indicated that randomized controlled trials are the most persuasive medical evidence that could
be included in guidelines and that locally developed study samples and case studies generally do not sway
their treatment strategies.
Ranking of Physician Preferences for Guideline Implementation -- Banner
SECTION I
Guideline Placement
Mean
Std.
Dev.
No
Preference
n
%
On front of patient chart
3.12
1.04
7
13.5
In progress notes
2.40
1.05
14
Palm pilot
2.30
1.20
18
Computerized medical record
2.08
1.17
At nurses' station
2.00
Pocket card
Slight
Preference
n
%
Moderate
Preference
n
%
Strong
Preference
n
%
24
46.2
4
7.7
17
32.7
26.9
9
17.3
20
38.5
7
13.5
34.6
11
21.2
9
17.3
12
23.1
23
44.2
7
13.5
11
21.2
8
15.4
1.02
20
38.5
17
32.7
8
15.4
6
11.5
1.96
1.08
24
46.2
11
21.2
10
19.2
6
11.5
On hospital/clinic website *
1.40
0.73
36
69.2
9
17.3
4
7.7
1
1.9
At patient bedside/in examination room *
1.38
0.64
35
67.3
11
21.2
4
7.7
0
0.0
* statistically equal @ p = 0.05
1 = No Preference, 2 = Slight Preference, 3 = Moderate Preference, 4 = Strong Preference
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
Page 8 of 18
Ranking of Physician Preferences for Guideline Implementation – Banner (cont.)
SECTION II
Learning Strategies
Mean
Std.
Dev.
No
Preference
n
Slight
Preference
n
%
%
Moderate
Preference
n
%
Strong
Preference
n
%
Discussions with colleagues
4.00
0.77
3
5.8
2
3.8
27
51.9
18
34.6
Continuing medical education *
3.06
0.97
5
9.6
7
13.5
19
36.5
20
38.5
Reminder notes/stickers on chart *
3.04
0.75
2
3.8
7
13.5
28
53.8
13
25.0
Clinical path reminder **
2.33
0.97
13
25.0
11
21.2
21
40.4
4
7.7
Verbal reminder from nurse **
2.31
1.03
14
26.9
14
26.9
16
30.8
7
13.5
Departmental memos **
2.16
0.89
13
25.0
19
36.5
15
28.8
3
5.8
Electronic physician newsletter
2.02
0.94
19
36.5
13
25.0
16
30.8
2
3.8
Verbal reminder from patient
1.96
1.01
22
42.3
12
23.1
12
23.1
4
7.7
*, ** statistically equal @ p = 0.05
SECTION III
Guideline Content
1 = No Preference, 2 = Slight Preference, 3 = Moderate Preference, 4 = Strong Preference
Mean
Std.
Dev.
Not at all
Useful
n
Not Very
Useful
n
%
Somewhat
Useful
n
%
%
Extremely
Useful
n
%
Immediate treatment flow
3.30
0.78
2
3.8
3
5.8
21
40.4
21
40.4
Discharge criteria
3.13
0.70
2
3.8
3
5.8
30
57.7
13
25.0
mild/moderate severity treatment
3.00
0.81
2
3.8
9
17.3
23
44.2
13
25.0
Panic thresholds
2.72
0.96
5
9.6
14
26.9
16
30.8
11
21.2
Strategies to encourage self-manage
2.71
0.87
5
9.6
12
23.1
23
44.2
8
15.4
Severity scoring system
2.63
1.00
9
17.3
9
17.3
21
40.4
9
17.3
References
2.43
0.93
8
15.4
17
32.7
16
30.8
6
11.5
1 = Not at all Useful, 2 = Not Very Useful, 3 = Somewhat Useful, 4 = Extremely Useful
SECTION IV
Guideline Format
Mean
Std.
Dev.
Not at all
Effective
n
Not Very
Effective
n
%
Somewhat
Effective
n
%
%
Extremely
Effective
n
%
Pre-printed orders
2.96
0.94
6
11.5
5
9.6
25
48.1
15
28.8
Algorithm *
2.92
0.84
4
7.7
8
15.4
28
53.8
12
23.1
Flowchart/flow diagram *
2.92
0.82
4
7.7
7
13.5
29
55.8
11
21.2
Order sets/templates
2.78
0.93
6
11.5
10
19.2
23
44.2
11
21.2
Check sheet
2.65
0.82
4
7.7
17
32.7
23
44.2
7
13.5
Decision tree
2.40
0.86
8
15.4
18
34.6
20
38.5
4
7.7
Clinical/care pathway
2.37
0.85
8
15.4
20
38.5
19
36.5
4
7.7
Interactive, computerized aid/QMR
2.15
0.91
13
25.0
17
32.7
14
26.9
3
5.8
Expert system
2.13
0.89
12
23.1
18
34.6
12
23.1
3
5.8
Computerized medical record
2.12
0.96
15
28.8
19
36.5
11
21.2
5
9.6
Disease/illness specific pamphlet
1.84
0.71
17
32.7
24
46.2
9
17.3
0
0.0
Comprehensive medical book
1.72
0.78
24
46.2
16
30.8
10
19.2
0
0.0
* statistically equal @ p = 0.05
SECTION V
Type of Evidence
1 = Not at all Effective, 2 = Not Very Effective, 3 = Somewhat Effective, 4 = Extremely Effective
Mean
Std.
Dev.
Not at all
Useful
n
Not Very
Useful
n
%
Somewhat
Useful
n
%
%
Extremely
Useful
n
%
Randomized controlled trial
3.71
0.64
1
1.9
2
3.8
8
15.4
41
78.8
Meta-analyses *
2.96
0.79
3
5.8
8
15.4
29
55.8
12
23.1
Expert consensus *
2.92
1.08
8
15.4
8
15.4
16
30.8
20
38.5
Independent original research
2.86
0.96
3
5.8
17
32.7
13
25.0
16
30.8
Nationally representative study sample
2.53
0.88
6
11.5
19
36.5
19
36.5
7
13.5
Case studies **
1.94
0.93
20
38.5
17
32.7
11
21.2
3
5.8
1.92
0.66
13
25.0
29
55.8
9
17.3
0
0.0
Locally developed study sample **
*, **, *** statistically equal @ p = 0.05
1 = Not at all Useful, 2 = Not Very Useful, 3 = Somewhat Useful, 4 = Extremely Useful
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
Page 9 of 18
The table above shows physician preferences for guideline implementation for Banner’s AMI guideline.
Banner physicians have a strong preference for guideline placement on the front of the patient chart, while
they do not favor guideline placement on a hospital/clinic website or at the patient bedside/in the
examination room. Banner physicians are most encouraged to use guidelines through discussions with
colleagues, continuing medical education, and reminder notes/stickers placed on the front of the patient
chart. Verbal reminders from the patient are least effective in encouraging guideline utilization. Banner
physicians find immediate treatment flows to be the most useful information included in guidelines, and that
references while important are not necessary at the time of patient treatment. Banner physicians prefer
guidelines in the form of pre-printed orders, algorithms, or flowcharts/flow diagrams, while the common
disease/illness specific pamphlets and comprehensive medical books are not useful formats at the time of
patient treatment. Banner physicians indicated that randomized controlled trials are the most persuasive
medical evidence that could be included in guidelines and that locally developed study samples and case
studies generally do not sway their treatment strategies.
Ranking of Physician Preferences for Guideline Implementation -- Summa
SECTION I
Guideline Placement
Mean
Std.
Dev.
No
Preference
n
%
Slight
Preference
n
%
Moderate
Preference
n
%
Strong
Preference
n
%
Palm pilot
2.96
1.15
12
15.2
11
13.9
15
19.0
32
40.5
On front of patient chart
2.80
1.21
18
22.8
9
11.4
18
22.8
30
38.0
Pocket card
2.73
1.22
17
21.5
16
20.3
11
13.9
30
38.0
In progress notes *
2.45
1.07
17
21.5
23
29.1
18
22.8
16
20.3
At nurses' station *
2.42
1.13
22
27.8
15
19.0
21
26.6
16
20.3
Computerized medical record
2.32
1.19
27
34.2
13
16.5
17
21.5
17
21.5
At patient bedside/in examination room **
1.74
0.87
37
46.8
19
24.1
14
17.7
2
2.5
On hospital/clinic website **
1.73
1.12
48
60.8
7
8.9
8
10.1
10
12.7
*, ** statistically equal @ p = 0.05
1 = No Preference, 2 = Slight Preference, 3 = Moderate Preference, 4 = Strong Preference
SECTION II
Learning Strategies
Mean
Std.
Dev.
No
Preference
n
%
Slight
Preference
n
%
Moderate
Preference
n
%
Strong
Preference
n
%
Continuing medical education *
3.23
0.80
2
2.5
11
13.9
29
36.7
32
40.5
Discussions with colleagues *
3.11
0.79
3
3.8
10
12.7
36
45.6
24
30.4
Clinical path reminder ****
2.74
0.97
10
12.7
16
20.3
31
39.2
17
21.5
Reminder notes/stickers on chart ****
2.65
1.03
13
16.5
17
21.5
27
34.2
17
21.5
Verbal reminder from nurse **
2.38
0.98
17
21.5
21
26.6
27
34.2
9
11.4
Departmental memos **
2.19
0.98
21
26.6
25
31.6
19
24.1
8
10.1
Electronic physician newsletter ***
1.93
0.80
25
31.6
29
36.7
18
22.8
1
1.3
Verbal reminder from patient ***
1.88
0.89
31
39.2
21
26.6
18
22.8
2
2.5
*, **, ***, **** statistically equal @ p = 0.05
1 = No Preference, 2 = Slight Preference, 3 = Moderate Preference, 4 = Strong Preference
SECTION III
Guideline Content
Mean
Std.
Dev.
Not at all
Useful
n
Not Very
Useful
n
%
%
Somewhat
Useful
n
%
Extremely
Useful
n
%
Strategies to minimize re-admits
3.30
0.84
2
2.5
12
15.2
22
27.8
38
48.1
Immediate treatment flow
3.20
0.78
2
2.5
10
12.7
33
41.8
29
36.7
Panic thresholds
3.12
0.78
1
1.3
15
19.0
32
40.5
26
32.9
Discharge criteria
3.03
0.81
5
6.3
8
10.1
41
51.9
20
25.3
Severity scoring system
2.99
0.82
2
2.5
19
24.1
31
39.2
22
27.8
mild/moderate severity treatment
2.89
0.73
3
3.8
15
19.0
43
54.4
13
16.5
References
2.77
1.01
11
13.9
15
19.0
28
35.4
20
25.3
1 = Not at all Useful, 2 = Not Very Useful, 3 = Somewhat Useful, 4 = Extremely Useful
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
Page 10 of 18
Ranking of Physician Preferences for Guideline Implementation – Summa (cont.)
SECTION IV
Guideline Format
Mean
Std.
Dev.
Not at all
Effective
n
Not Very
Effective
n
%
Somewhat
Effective
n
%
%
Extremely
Effective
n
%
Algorithm
3.24
0.81
3
3.8
8
10.1
31
39.2
32
40.5
Flowchart/flow diagram
3.12
0.81
3
3.8
11
13.9
34
43.0
26
32.9
Pre-printed orders
3.03
0.88
4
5.1
15
19.0
29
36.7
25
31.6
Decision tree
2.89
0.92
6
7.6
17
21.5
30
38.0
21
26.6
Check sheet
2.82
0.91
7
8.9
17
21.5
32
40.5
18
22.8
Clinical/care pathway
2.68
0.89
9
11.4
18
22.8
35
44.3
12
15.2
Order sets/templates
2.67
0.77
4
5.1
25
31.6
34
43.0
9
11.4
Interactive, computerized aid/QMR
2.61
0.93
9
11.4
23
29.1
27
34.2
13
16.5
Computerized medical record *
2.53
1.11
17
21.5
20
25.3
18
22.8
19
24.1
Expert system *
2.51
0.95
12
15.2
22
27.8
26
32.9
11
13.9
Disease/illness specific pamphlet
2.19
0.90
18
22.8
30
38.0
20
25.3
6
7.6
Comprehensive medical book
2.10
0.97
23
29.1
26
32.9
16
20.3
7
8.9
* statistically equal @ p = 0.05
1 = Not at all Effective, 2 = Not Very Effective, 3 = Somewhat Effective, 4 = Extremely Effective
SECTION V
Type of Evidence
Mean
Std.
Dev.
Not at all
Useful
n
Not Very
Useful
n
%
Somewhat
Useful
n
%
%
Extremely
Useful
n
%
Randomized controlled trial
3.73
0.50
0
0.0
2
2.5
16
20.3
56
70.9
Nationally representative study sample
3.11
0.73
1
1.3
13
16.5
37
46.8
23
29.1
Expert consensus
3.07
0.67
1
1.3
11
13.9
44
55.7
18
22.8
Meta-analyses *
3.01
0.79
3
3.8
13
16.5
37
46.8
20
25.3
Independent original research *
3.00
0.98
7
8.9
14
17.7
25
31.6
28
35.4
Locally developed study sample **
2.36
0.75
9
11.4
32
40.5
29
36.7
3
3.8
2.34
0.82
9
11.4
38
48.1
20
25.3
7
8.9
Case studies **
*, ** statistically equal @ p = 0.05
1 = Not at all Useful, 2 = Not Very Useful, 3 = Somewhat Useful, 4 = Extremely Useful
The table above shows physician preferences for guideline implementation for Summa’s AMI guideline.
Similar in almost every respect to Banner physicians, Summa physicians prefer guideline placement on
their individual palm pilot or on the front of the patient chart, while they do not favor guideline placement on
a hospital/clinic website or at the patient bedside/in the examination room. Summa physicians are most
encouraged to use guidelines through discussions with colleagues and continuing medical education.
Electronic newsletters and verbal reminders from the patient are least effective in encouraging guideline
utilization. Summa physicians find strategies to minimize re-admits to be the most useful information
included in guidelines, and that references while important are not necessary at the time of patient
treatment. Summa physicians prefer guidelines in the form of pre-printed orders, algorithms, or
flowcharts/flow diagrams, while the common disease/illness specific pamphlets and comprehensive
medical books are not useful formats at the time of patient treatment. Summa physicians indicated that
randomized controlled trials are the most persuasive medical evidence that could be included in guidelines
and that locally developed study samples and case studies generally do not sway their treatment
strategies.
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
Page 11 of 18
Ranking of Physician Preferences for Guideline Implementation -- Trinity
SECTION I
Guideline Placement
Mean
Std.
Dev.
No
Preference
n
%
Slight
Preference
n
%
Moderate
Preference
n
%
Strong
Preference
n
%
On front of patient chart
3.04
1.04
36
12.0
45
15.0
84
28.0
129
43.0
In progress notes
2.44
1.07
78
26.0
63
21.0
99
33.0
54
18.0
Computerized medical record **
2.33
1.25
111
37.0
45
15.0
48
16.0
78
26.0
At nurses' station **
2.30
1.12
102
34.0
45
15.0
93
31.0
48
16.0
Palm pilot **
2.21
1.21
123
41.0
45
15.0
57
19.0
63
21.0
Pocket card
2.17
1.14
117
39.0
54
18.0
69
23.0
48
16.0
On hospital/clinic website *
1.87
1.00
141
47.0
75
25.0
48
16.0
27
9.0
At patient bedside/in examination room *
1.84
0.96
147
49.0
63
21.0
69
23.0
15
5.0
*, ** statistically equal @ p = 0.05
SECTION II
Learning Strategies
1 = No Preference, 2 = Slight Preference, 3 = Moderate Preference, 4 = Strong Preference
Mean
Std.
Dev.
No
Preference
n
%
Slight
Preference
n
%
Moderate
Preference
n
%
Strong
Preference
n
%
Continuing medical education *
3.20
0.78
9
3.0
36
12.0
129
43.0
111
37.0
Discussions with colleagues *
3.14
0.75
6
2.0
45
15.0
138
46.0
96
32.0
Reminder notes/stickers on chart
2.76
0.93
30
10.0
75
25.0
114
38.0
66
22.0
Clinical path reminder **
2.51
0.88
42
14.0
84
28.0
123
41.0
30
10.0
Verbal reminder from nurse **
2.45
1.02
72
24.0
51
17.0
123
41.0
39
13.0
Verbal reminder from patient
2.24
1.12
105
35.0
54
18.0
78
26.0
48
16.0
Departmental memos
2.19
0.84
66
22.0
111
37.0
96
32.0
12
4.0
Electronic physician newsletter
2.11
0.82
69
23.0
129
43.0
75
25.0
12
4.0
*, ** statistically equal @ p = 0.05
SECTION III
Guideline Content
1 = No Preference, 2 = Slight Preference, 3 = Moderate Preference, 4 = Strong Preference
Mean
Std.
Dev.
Not at all
Useful
n
Not Very
Useful
n
%
Somewhat
Useful
n
%
Extremely
Useful
n
%
%
Strategies to encourage self-manage
3.20
0.72
6
2.0
30
10.0
141
47.0
96
32.0
Discharge criteria *
3.16
0.74
9
3.0
15
5.0
117
39.0
66
22.0
Immediate treatment flow *
3.16
0.75
12
4.0
21
7.0
150
50.0
90
30.0
Panic thresholds *
2.98
0.97
30
10.0
39
13.0
108
36.0
93
31.0
mild/moderate severity treatment
2.89
0.82
15
5.0
60
20.0
129
43.0
60
20.0
Severity scoring system
2.85
0.87
24
8.0
54
18.0
135
45.0
60
20.0
References
2.36
0.87
48
16.0
96
32.0
102
34.0
21
7.0
* statistically equal @ p = 0.05
SECTION IV
Guideline Format
1 = Not at all Useful, 2 = Not Very Useful, 3 = Somewhat Useful, 4 = Extremely Useful
Mean
Std.
Dev.
Not at all
Effective
n
Pre-printed orders
2.93
0.92
27
Flowchart/flow diagram
2.90
0.86
Algorithm
2.82
0.90
Check sheet
2.78
Order sets/templates
Not Very
Effective
n
%
%
Somewhat
Effective
n
Extremely
Effective
n
%
%
9.0
54
18.0
126
42.0
87
29.0
21
7.0
63
21.0
135
45.0
75
25.0
30
10.0
63
21.0
135
45.0
69
23.0
0.86
30
10.0
60
20.0
150
50.0
54
18.0
2.73
0.95
39
13.0
63
21.0
123
41.0
63
21.0
Decision tree
2.68
0.78
27
9.0
69
23.0
165
55.0
30
10.0
Clinical/care pathway
2.58
0.86
39
13.0
75
25.0
141
47.0
33
11.0
Computerized medical record **
2.28
1.10
93
31.0
72
24.0
72
24.0
51
17.0
Disease/illness specific pamphlet **
2.20
0.95
78
26.0
108
36.0
78
26.0
30
10.0
Interactive, computerized aid/QMR
2.10
0.94
99
33.0
75
25.0
99
33.0
15
5.0
Comprehensive medical book *
1.97
0.88
99
33.0
120
40.0
54
18.0
18
6.0
Expert system *
1.97
0.87
96
32.0
102
34.0
63
21.0
12
4.0
*, ** statistically equal @ p = 0.05
1 = Not at all Effective, 2 = Not Very Effective, 3 = Somewhat Effective, 4 = Extremely Effective
CHMR Progress Report Summary – 05/04/01
Organizational & Clinical Factors Influencing Use of CPGs
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Ranking of Physician Preferences for Guideline Implementation – Trinity (cont.)
SECTION V
Type of Evidence
Mean
Std.
Dev.
Not at all
Useful
n
Not Very
Useful
n
%
Somewhat
Useful
n
%
Extremely
Useful
n
%
%
Randomized controlled trial
3.29
0.78
15
5.0
15
5.0
135
45.0
129
43.0
Expert consensus
3.11
0.77
12
4.0
36
12.0
156
52.0
93
31.0
Independent original research
2.97
0.91
21
7.0
63
21.0
114
38.0
96
32.0
Meta-analyses *
2.79
0.84
24
8.0
66
22.0
147
49.0
54
18.0
Nationally representative study sample *
2.74
0.96
42
14.0
60
20.0
129
43.0
66
22.0
Locally developed study sample
2.24
0.87
63
21.0
120
40.0
93
31.0
21
7.0
2.12
0.86
75
25.0
126
42.0
75
25.0
18
6.0
Case studies
* statistically equal @ p = 0.05
1 = Not at all Useful, 2 = Not Very Useful, 3 = Somewhat Useful, 4 = Extremely Useful
The table above shows physician preferences for Trinity’s Pediatric Asthma and AMI guideline. Trinity
physicians prefer guideline placement at the patient bedside/in the examination room or on the
hospital/clinic website, while they do not favor guideline placement on the front of the patient chart. Trinity
physicians are most encouraged to use guidelines through discussions with colleagues and continuing
medical education. Electronic newsletters and departmental memos are least effective in encouraging
guideline utilization. Trinity physicians find strategies to minimize re-admits/encourage self-management to
be the most useful information included in guidelines, and that references while important are not
necessary at the time of patient treatment. Trinity physicians prefer guidelines in the form of pre-printed
orders, algorithms, or flowcharts/flow diagrams, while expert systems and comprehensive medical books
are not useful formats at the time of patient treatment. Trinity physicians indicated that randomized
controlled trials are the most persuasive medical evidence that could be included in guidelines, and that
locally developed study samples and case studies generally do not sway their treatment strategies.
Our review of prior relevant literature revealed the need to determine effective ways to disseminate and
implement CPGs. Current quality management methods encourage managers to seek input from the
primary users of information, yet physicians are not being formally asked whether they have specific
preferences for implementing CPGs. The results of this study revealed that physicians do have specific
preferences for CPG implementation with respect to guideline placement, format, content, learning
strategies, and type of medical evidence. Our research indicates that some of these areas are consistently
preferred by physicians regardless of treatment setting (in patient/outpatient), specialty, or health system
configuration, while others appear to be physician/organization characteristic specific. The key findings and
success factors that can be used by all health systems during guideline implementation are summarized
below:
WHAT PHYSICIANS CONSISTENTLY WANT FROM GUIDELINES USED AT THE TIME OF PATIENT TREATMENT:
1. Continuing medical education still appears to be an effective tool for educating and
encouraging physician use of guidelines.
Recommendation: The practice of using CME to educate and encourage guideline use should be
continued.
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Organizational & Clinical Factors Influencing Use of CPGs
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2. Physicians are persuaded by other colleagues to use guidelines in practice.
Recommendation: This finding supports the role of physician champions in guideline implementation
efforts. Whenever possible, physician champions should be included in guideline development and
dissemination efforts.
3. Strategies to minimize re-admits/encourage self-management and immediate treatment flows
are two areas consistently cited by physicians as most useful at the time of patient treatment .
Recommendation: All guidelines should be updated to include this information if it is not already
present.
4. Physicians consistently indicated that the most user-friendly guideline formats are
flowcharts/flow diagrams and algorithms.
Recommendation: Guidelines adopted by health systems should be prepared as brief (1 page front &
back) clinical summaries with graphics/treatment flow diagrams to assist physicians with following
treatment recommendations.
5. Physicians consistently cited randomized controlled trials as the most persuasive medical
evidence.
Recommendation: Whenever possible, randomized controlled trials should be the primary medical
evidence used in guideline development.
WHAT PHYSICIANS CONSISTENTLY DO NOT FIND NECESSARY IN GUIDELINES USED AT THE TIME OF PATIENT
TREATMENT:
1. Departmental memos and electronic newsletters are not effective means of educating and
encouraging physician use of guidelines.
Recommendation: Time and resources spent on these activities is not effective and could be better
used in other areas such as medical education.
2. While citing references is an important part of guideline development, physicians consistently
feel that references are not a necessary component of guidelines used at the time of treatment.
Recommendation: According to physician comments, if space is limited on a guideline, guideline
developers should include a note indicating where full references could be found rather than including
full references in lieu of treatment specific content information.
3. Commonly used disease/illness specific pamphlets and comprehensive medical books are not
useful formats for disseminating clinical treatment information at the time of patient treatment.
Recommendation: The more detailed information provided through these formats is not necessary for
immediate patient treatment and therefore should be stored in a common area for physician access.
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Organizational & Clinical Factors Influencing Use of CPGs
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4. Locally developed study samples and case studies are the least persuasive forms of medical
evidence.
Recommendation: While some literature indicates that local case studies and study samples can
encourage physician use of guidelines, our research indicates that time and resources invested in
these activities are only marginally effective and lack credibility consistently among all physicians.
INCONSISTENT FINDINGS IN THE RESEARCH:
1. Significant differences were found in physician preferences for guideline placement.
Recommendation: While over all physicians seemed to prefer guidelines placed on the front of the
patient chart, on their personal palm pilot, or in the progress notes, and that placement at the patient
bedside/in the examination room or on the hospital/clinic website were not preferred, these findings
were not consistent throughout all health systems.
2. Significant differences were found in the role patients can play in encouraging physician use of
guidelines.
Recommendation: While overall physicians seemed to feel that verbal reminders from patients were
not an effective means of encouraging guideline utilization, these findings were not consistent
throughout all health systems. Our final analyses will include a thorough analysis to determine the root
causes of these differences based on guideline used, treatment setting, physician specialty, and
organizational characteristics.
Phase II – Qualitative Methods Progress (PI: Seema S. Sonnad, Ph.D.)
The Guideline Process and the Health System Structure: A Qualitative Investigation
Goals of the Research
The purpose of this study was to examine how health systems differ in their approach to and success with
guideline development and implementation. Specific questions:
1) How does being part of a system affect the guideline process positively or negatively
2) How has the structure and culture of the health system impacted how guidelines are developed and
implemented. Have system structure and culture had effects on guideline success or failure.
3) What do individuals perceive the system as doing well and what do they see as primary needs the
system must address for guidelines to meet their goals.
Key Findings
The term integrated health system encompasses many structures and relationships. The structures and
goals of integrated systems change routinely. System structures and goals obviously impact guideline
development and implementation. The aspects of system structure and culture that this study revealed as
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Organizational & Clinical Factors Influencing Use of CPGs
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most important to the guideline process are:
1) The degree of availability of data systems that allow measurement of specific patient populations at the
level of the clinical encounter.
2) Support of upper level management, both in understanding the guideline process and in providing
personnel and data resources to the process.
3) The nature of the relationship between the system and the physicians providing care to the systems
patients, encompassing both cultural and fiscal relationships.
4) The degree to which the guidelines process is integrated with other methods and programs important to
the system's primary strategic goals.
5) The degree to which it is possible to involve physicians in the guidelines process.
Barriers and Facilitators within Health Systems
Each of the systems participating in this study experienced both successes and failures in their attempts
with guidelines. Across systems, although with different degrees of relative importance within each system,
the following appear to hold.
Successes are facilitated by:
1) active and informed physician champions
2) availability of data to provide information and feedback
3) implementation methods that embed the guideline recommendations into the routine processes of
patient care already in place
4) provision of personnel and data resources directly to the guideline process
5) selection of guidelines in areas key to the systems core goals
Primary barriers appear to be:
1) relationships between physicians and systems that do not lend themselves to incentive alignment
2) difficulty in identifying patients or collecting patient level clinical data for the condition addressed by the
guideline
3) lack of understanding of the guideline process and needs at the upper levels of management
4) conflicting rather than integrated goals related to other quality improvement efforts
Differences across Systems
Despite commonalties, there are important differences across systems and these differences in the
guideline process are strongly driven by system structure and system relations. The most obvious
differences were:
1) Variation in selection of area on which to focus guideline efforts
 Inpatient versus outpatient care
 Primary care versus specialty care
2) Method for selecting physician champion
 Specialty area related to guideline
 Geographic location at facility
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 Member of physician leadership/administration
3) The degree to which data based feedback and monitoring is used and thechoice of aggregate versus
individual level feedback
4) The position of the guideline process within the organizational structure
5) Extent of focus on "guidelines" versus other related tools
Wish Lists within Systems
Because system structure affects the guideline process, and each system had a slightly different structure,
there were differences in the ranking of the "wish lists" of those involved in the guideline process. However,
these three items appeared somewhere within each system:
1) Clinical data system or electronic medical record to allow monitoring and data collection at individual
patient level.
2) Methods of providing incentives (financial or other) to encourage physician involvement in the guidelines
process
3) Greater participation of top leadership in and/or greater access for individuals to training in
guidelines/process improvement.
Summary
Guidelines are one method used to reach common system goals of improved patient care management,
both to provide higher quality care and to improve the finances of doing so. If guidelines are to contribute
fully to those goals, it is important that health system leadership understand their strengths and
weaknesses as related to the guideline process and do what is feasible to facilitate success and remove
barriers.
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Organizational & Clinical Factors Influencing Use of CPGs
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