Obstacles That Slow Guidelines Implementation

FORT LAUDERDALE, Fla--The most difficult part of the guidelinesprocess is implementation--getting physicians, nurses, and administratorsto "buy in" to the process, Gale Katterhagen, MD, saidat the first annual conference of the National Comprehensive CancerNetwork (NCCN), a coalition of major cancer centers currentlyin the process of developing guidelines for its members.

The real moment of truth for any guideline or clinical path, Dr.Katterhagen said, is the documentation that outcomes and costshave been impacted.

"Has the guideline produced value for the institution? Unlessclinical guidelines affect physicians' prescriptive practices,and drive practice variation and inappropriate care out of thesystem," he said, "they will not have a significantimpact on costs and outcomes."

The market is driving the process, with purchasers demanding accountabilityin costs and outcomes. When purchasers talk about quality, hesaid, they are really talking about outcomes--patient satisfaction;clinical outcomes, both morbidity and mortality; and quality oflife (which is now often referred to as "functionality").Purchasers want good value, as defined by the equation: outcomesdivided by costs.

Dr. Katterhagen has direct experience with the guidelines processin his role as chairman of the Clinical Quality Council for theSan Francisco-based, 23-hospital, not-for-profit Sutter-CaliforniaHealthcare System.

He said that at Mills-Peninsula Hospitals, Burlingame, where heis medical director of the Cancer System and Breast Center, physiciansare deeply involved from the outset in the development of clinicalpaths. The development groups "work backwards," he said,first defining outcomes, then selecting the process, or orderset, to be followed for the specific DRG or condition.

Over the course of 3 years of involvement in the guidelines process,Dr. Katterhagen said that he has learned to anticipate many ofthe obstacles to implementation:

Aversion to change. "People don't like change, butwith the expediency of the situation in California markets, wedon't have a lot of time to work with people," he said. "Theyhave to just get on the wagon and work as a team for implementationof the clinical path or guideline."

He added that in most cases, the institutional culture and infrastructureare also hostile to change. "Too often programs are viewedas pilot programs rather than as a basic part of the businessstrategy of the institution," he said. Practically all currentquality efforts are process or structure based, but success requiresthat the institutional culture and infrastructure become outcomesoriented. "Once that starts to develop, then implementationgets easier," he said.

Inadequate support at all levels. Top management must supportthe program along with the hospital's medical leadership and keypoint-of-care people, including physicians, point-of-care nurses,respiratory and physical therapists, and nurse managers.

This may require one-on-one work with individuals, "so weimplement an inpatient path in only one nursing unit at a time,"he said.

Without adequate preparation for the program, nurses and othersmay write it off as "just another fad." With cuts andlayoffs, nurses are working harder and have had so many programsfoisted on them by senior management, "they may not realizethat clinical paths are not just going to going away," hesaid.

A lack of "systems thinking." Even in the capitatedenvironment, Dr. Katter-hagen said, "we still find departmentalthinking (I'm the lab; I'm radiology, etc)." In fact, hesaid, under capitation there are no more profit centers, justcost centers, "and we've got to think systems instead ofturf."

At the start of the clinical paths program at his hospital, Dr.Katterhagen said, he "saw most of the clinical paths oftensitting on the shelf." The missing ingredient was that themedical staff did not reach out and say, 'This is ours.'

He noted that being a physician himself helped him to foster aculture of acceptance. "It often takes one-on-one discussionswith physician to get them to use guidelines," he said, mentioningthe "80-20 rule": Spend 80% of your time with the 20%of the medical staff who are most important.

If physicians buy in, he said, they will drive everything else--nursing,respiratory therapy, CEO. But if physicians don't buy in, theCEO and nurses will not drive physicians. "You've got toget the doctors on board."

Physicians must become aware that they are accountable, and themost graphic way of doing this is by physician profiling. Physicianswho don't measure up will be "deselected, a kinder, gentlerway to say you're fired," he said.

Dr. Katterhagen pointed out that physicians themselves are doingthe firing; physicians groups, independent practice associations(IPAs), etc, have too many specialists to be efficient. "Inour area," he said, "there is 50% too much of almosteverything in cancer; 50% too many beds, 50% too many oncologists,and the market is going to drive this overcapacity and waste outof the system."

For physicians to fully accept clinical paths, they must workthrough the old issues of control and autonomy.

"I hear the 'cookbook' business less and less," he said."It's a hollow argument because, after all, if you can getpast the emotional aspect of the issue, a cookbook is just a seriesof outcomes (meals) with an excellent process (recipes)."

He said that he continuously shares data on the program with thephysicians involved. "We have had real converts when we showthe impact on quality and, secondarily, the impact on costs."

For example, he said, implementation of the clinical path forDRG 75 (thoracic surgery) led to reductions in postoperative confusion,which contributed to reductions in length of stay and significantsavings; surgical mortality rates also fell.

For the clinical path for DRG 148 (major small and large bowelprocedures), costs were reduced significantly after implementation,due primarily to "doing the right bowel prep and not usingDemerol," he said.

The guideline for use of the antiemetic agent ondansetron (Zofran)stated that it would not be used except in highly emetogenic groupsor single-agent chemotherapy, and if used, the dose should be8 mg, not 32 mg. In addition, anti-emetic agents similar to ondansetronwould no longer be stocked.

He said that acceptance of this clinical path was "almostovernight because we worked closely with the medical oncolo-gists,showing them the literature, especially on the dosing controversy."Post-implementation monitoring showed a significant cost savingswith no increase in chemotherapy-related emesis.

As for the older physicians who "just won't change,"Dr. Katterhagen said that retirement is taking its toll, "andthat's one way of solving that problem."