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SUMMARY 12 RECOMMENDATIONS: IMPLEMENTATION AND EVALUATION Although AHCPR and the Forum are responsible for implementing the government program for guidelines established in OBRA 89, the main work of implementing the guidelines themselves will be in the hands of physicians, nurses, health care administrators, and others. The agency, however, has important responsibilities for evaluating the impact of guidelines. The committee's discussions were limited by its charge and centered primarily on how the processes of implementation and evaluation can reinforce and extend the eight attributes of guidelines defined earlier. One committee recommendation is that the agency instruct its expert panels and contractors to keep implementation and evaluation in mind as they develop guidelines. The tension between extraordinarily detailed or sophisticated guidelines and those that can be translated into usable medical review criteria or patient education materials must be recognized and dealt with during the development process, not after the fact. Keeping implementation and evaluation in mind during guidelines development means, among other things, understanding the following. ⢠The credibility of the development process, the participants, and the scientific grounding of guidelines must be clear to intended users. ⢠A truly multidisciplinary approach to guidelines development will facilitate acceptance and use of guidelines by members of the groups represented and by other, secondary target groups. ⢠Guidelines should be specific, comprehensive, and flexible enough to be useful in the varied settings and circumstances of everyday medical practice and in the evolving programs to assess the appropriateness of care provided in these settings. ⢠Guidelines language, logic, and symbols should be easy to follow and unambiguous, so that movement from guidelines statements to educational tools, review criteria, or other instruments is unimpeded. ⢠The guidelines should specify what information about the clinical problem, the patient's circumstances and preferences, and the delivery setting should be recorded to permit later evaluation of the appropriateness of care (judged against criteria generated from the guidelines). The implementation of guidelines is a diffuse, difficult-to-track process that will depend on many factors besides the quality and credibility of the guidelines. Among those factors are (1) the funding for dissemination and other implementation activities; (2) the supports and incentives for the guidelines to be used by physicians, nurses, health plans, and others; (3) the accessibility, scope, accuracy, and timeliness of a variety of intra- and interorganizational information systems; and (4) the ability of multiple parties to plan and execute the various steps needed to implement guidelines.
SUMMARY 13 Users of guidelines will vary in their objectives and circumstances, and strategies for meeting particular user objectives will differ in their cost-effectiveness and manageability. Thus, different objectives and resources may call for different choices among the formats for guidelines (that is, their physical layout and logic), different roles for the available dissemination media, and different kinds of administrative supports for users of guidelines. Organizations with more resources (for example, libraries, video centers, telephone hotlines, personal computers, and network information systems) will be able to assist the use of guidelines in ways that are out of reach for less resource-rich organizations. Medical review criteria and other evaluation instruments, if properly developed and sensitively applied, can create incentives for adherence to practice guidelines. If improperly developed and applied, they can undermine support for practice guidelines. Building on earlier IOM reports on utilization management and quality assurance, the committee discussed a few broad principles for the constructive use of medical review criteria and other evaluation tools derived from practice guidelines. First, review criteria should be public with respect to their content and their development process. Second, when criteria are used to assess quality of care, deny payment for specific services, or take similar steps, an appeals process must be provided that is free from unreasonable complexity, delay, or other barriers. Third, review organizations should provide constructive information and feedback to physicians and other clinicians with the aim of improving practice rather than punishing missteps. Fourth, review organizations should make their review activities as manageable and nonintrusive as possible. Such organizations contribute to the perceived and real ''hassle factor" in medical care, which grows out of burgeoning demands by payers and others for more information on, and justification for, health services delivered or proposed. The Forum needs to be sensitive to this issue. It should also work with HCFA and other organizations to minimize negative effects from poor translation of otherwise good guidelines into review criteria, unduly stringent application of these criteria, or both. The committee recognizes the critical importance of strong systems support for implementation. The complexities of creating such support within and across organizations are beyond the scope of this report but will be an important issue in further IOM work on practice guidelines. With respect to the evaluation responsibilities of AHCPR and the Forum, the committee believes that the OBRA 89 provisions for evaluation are laudable but that the timetable is unrealistic. The Secretary of Health and Human Services is due to report on the impact of the first three guidelines by January 1, 1993. It is unlikely that measurable effects of these guidelines on the costs or quality of care will appear that quickly, and
