From guidelines to seamless care Minna Kaila, MD, PhD Chief Physician, Department of General Practice Pirkanmaa Hospital District.

From guidelines to seamless care

Minna Kaila, MD, PhDChief Physician, Department of General

PracticePirkanmaa Hospital District

Guideline?

Clinical practice guideline

”Systematically developed statement, based on scientific evidence, on the diagnosis and treatment of a disease”

To help decision making (physician, other health care professionals, patients)

To improve quality in Health care

Motivation for guidelines

Study 1995: 719 guidelines & regional treatment programs in 5 years– length, structure and quality varied – duplicate work

Registry data on practice variation– elective procedures, e.g. cataracts, cesareans– medication, e.g. asthma, hypertension

National strategy promoting EBHC Specialists interested in better guidelines

Varonen & Mäkelä. Practice guidelines in Finland: availability and quality.Qual Health Care 1997;6:75-9

Health policy or clinical decisions

Primary laboratory research

Other primary

research

Primary clinical

research

Epidemio- logic data

Economic evaluations

Systematic review

Clinical guidelineHealth technology

assessment

Study StudyStudyStudy

Systematic organisation of information

Values Resources

Evidence

Practical applications: Care pathways, training

programmes

Evidence Based HealthCare

13 translations

Evaluation of guideline quality

www.agreecollaboration.org

Käypä hoito - Current CareGuideline Programme

Medical Society Duodecim Specialist societies Funding: Ministry of Social Welfare&Health To

– collect and update scientific knowledge of essential health problems

– make the information available in health care – evaluate the effects

Topics: common chronic conditions, new methods dgn/Rx, variation documented

Publication – in Finnish

Lääkärin CD-rom (EBMG) – most of PHC

– innovative electronic publication since 1989

Internet – http://www.kaypahoito.fi(free access)– http://www.terveysportti.fi(portal) – all hospital districts,

most health centres

Medical Journal Duodecim – almost all MDs– full guideline, summaries, update summaries

Patient version in Hyvä Terveys – health magazine with widest circulation

Updates in electronic format only (~3 years)

www.kaypahoito.fi

J.Briggs Inst.for Evid.Based Nursing&Midwifery, AUS National Institute of Clinical Studies NICS, AUSAustrian Ass.for Quality in Healthcare, ABelgian Center for Evidence based Medicine, BFlemish College of General Practitioners, BProgram in Evidence-based Care, Cancer Care Ontario, CDNDanish Guidelines Secretariat, DKFinnish Medical Society Duodecim, FINFinnish Office for HTA FINOHTA, FINFrench Nat.Agency for Accred., Eval in Healthcare ANAES, FFrench National Federation of Cancer Research Centres, FGerman Association of Scientific Medical Societies AWMF, DBerlin Chamber of Physicians, DGerman Agency for Quality in Medicine ÄZQ, DRoyal College of Surgeons in Ireland RCSI, IRL Iceland Directorate of Health, ISLItalian Evidence-Based Medicine Group GIMBE, IRegional Health Agency Emilia-Romagna, IMalaysian Ministry of Health, MAL New Zealand Accident Compensation Corporation, NZNew Zealand Guidelines Group, NZ Norwegian Directorate for Health and Social Affairs, NOPolish Institute for EbM, PLPolish Soc.for Quality Promotion in Healthcare, PLPortuguese Institute for Quality in Healthcare, PORSlovene Guidelines Group, SLOBasque HTA Office OSTEBA, EJosep Laporte Library Foundation, Barcelona, ESwedish Board of Health and Welfare (Socialstyrelsen), S Clinical Epidemiology Center Lausanne , CHSwiss Medical Association FMH, CHDutch Association of Comprehensive Cancer Centres, NL  Dutch College of General Practitioners, NLDutch Institute for Healthcare Improvement CBO, NLNational Institute for Clinical Excellence NICE, UKCentre for Reviews & Dissemination York, UKScottish Intercollegiate Guidelines Network, UKSowerby Centre for Health Informatics at Newcastle, UKAgency for Health Research & Quality AHRQ, USA National Kidney Foundation, USAAGREE Collaboration, INTWorld Health Organisation Geneva WHO, INT

Membership

April 2003

www.g-i-n.net

Definitions

Diffusion - just published for everybody to use

Dissemination – in addition, actively distributed to end users

Implementation – change management, CPD, localization of guidelines

Localizing, adopting, adapting

Why > Systematic review or study

What > (National) guideline How > (National) guideline Localised guideline Where > Localised guideline By whom > Localised guideline When > Treatment plan/appointm.

Care pathway

Health centerHospitalSocial work

Private

Helathy n=?At risk n=?Acutely ill n=?Chronically ill n=?

Clinical Value Compass

Functional levelClinical pictureSatisfactionCosts

Seamless care

Social Insurance Institution

Patient or information

PH

C

ER

Rad

Lab

Ped

Seamless Care

Existing Clinical Practice Guidelines Problems / need detected at the grass roots level

Toimittaja AsiakasProcessSyöte Palvelu /

tuote

( Input) ( Output )

Currently: need for change? problems?

totuus

tulevaisuusturva

tuska

taika

työ

teko

Localize Clinicians (opinion leader) Users (health care professionals) Based on the available evidence (national

guidelines) Agree on process of care Measures! Audit criteria! Concise, electronic, linked to essential

knowledge

In practice?

Kuhmoinen

Jämsä

Lavia

Keuruu

Multia

Punkalaidun

MänttäVilppula

KangasalaSahalahti

ViialaValkeakoskiVesilahti

Lempäälä

PirkkalaNokia

ÄetsäVammala

MouhijärviKiikoinen

Suodenniemi

Ikaalinen

Viljakkala

Hämeenkyrö

Parkano

Kihniö

YlöjärviTampere

PälkäneLuopioinen

Kuhmalahti

OrivesiLängelmäki

Juupajoki

Ruovesi

Virrat

Kuru

Toijala

UrjalaKylmäkoski

Jämsänkoski

Asthma

Building shared vision

Telling

Selling

Testing

Req

uir

ed

cap

aci

ty

for

dir

ect

ion

sett

ing

an

d learn

ing

Degree of active involvement

Consulting

Co-creating

Senge P, Kleiner A, Roberts C, Ross R, Smith B. The fifth discipline fieldbook. Nicholas Brealey Publishing, London 1996.

Free access! Also patients

495

Electronic decision aids

Based on the diagnosis that the physician makes /codes

Electronic Patient Record

If ATC = ’J01C’then show reminder ’Allergic to penicillin!’

...direct links to the appropriate part of the practice guideline

...pop up cautions, alerts etc. are being formulatedMD Ilkka Kunnamo &al, Evidence Based Medicine Guidelines, Duodecim

Department of General Practice

NHS joint working party report 2004:

’...joint approaches at the local level...setting up joint clinical directorates that span primary and secondary care’

’..routine joint review of clinical incidents...progress with initiatives such as ...the use of national guidelines and agreed local evidence-based formularies’

Guidelines to seamless care

An existing gl A problem in coordination of care (betweeen PHC

and secondary care) Involve relevant clinicians, form a working group Document current practice Agree on coordination, document Electronic publication CPD, education, learning Regular update

Sanity and management guidelines.

JO Warner. PAI 2001

sane - carefully assimilates all evidence and then acts on the basis of that evidence

insane - ignores all the evidence and says and does what is in his / her head

unsane - an attempt to at least consider the evidence, but then only to accept the evidence that is concordant with what is in the individual’s head. ----