Adherence to evidence-based clinical practice (EBP) is linked to better care quality and improved health care outcomes.1 Despite this link, consistent application of EBP in patient care remains a challenge for health care providers.2 Recent studies highlight limited application of generally accepted evidence-based clinical practices as well as limited application of more recent discoveries and recommendations. Reasons for the slow response point to a combination of factors often involving the clinician, the environment in which the clinician practices, the implementation approach, and the strength of the evidence that defines the EBP, as well as the intervention protocol designed to improve the use of EBP through the creation of guidelines.3
Intermountain Healthcare's (Intermountain) initial efforts to embed EBP more consistently into care began in the 1980s under the leadership of Dr Brent James. Bringing together clinical and administrative leaders, a “Key Process Analysis” was conducted to understand the relative volume, patient impact, improvement opportunity, and cost associated with the key “care processes” of the organization. From this exploratory work, multidisciplinary “Clinical Programs” were sequentially established in 10 areas such as cardiovascular and women's and newborn care and tasked with responsibility for building, validating, and embedding EBPs (as revealed by the Key Process Analysis) into routine clinical care. Clinical Programs, in partnership with others including Data and Analytics, were also responsible for building the clinical and operational data systems that were required to measure the adoption and the clinical and financial impact of the EBP guidelines. In their most mature form, these clinical EBP guidelines came to be called Care Process Models (CPMs) at Intermountain.
CPMs were developed by each of the clinical programs to summarize clinical literature and offer evidence-based approaches to care for specific conditions. Over time, the number of clinical programs and the CPM library grew with the changing medical care needs of the community and with new discoveries. In recent years, the move to the iCentra (Cerner) electronic health record provided more robust electronic workflow capabilities, including algorithm-driven alerts and reminders, to support clinical care process adherence.
Despite the promise of this work and early successes associated with the CPMs, like many health care organizations, Intermountain has challenges with variation in the application and use of evidence-based CPMs across clinical areas and across the spectrum of care delivery. To better understand the knowledge, attitudes, and beliefs of the clinical teams in driving variation in the use of CPMs, Intermountain conducted a field survey including more than 100 clinicians (including physicians and nurses) from across the organization. The results of this important work identified several barriers to CPM use including:
- Inconsistent alignment of CPMs with the strategic priorities of the organization and the needs of frontline staff
- Clinician beliefs regarding the strength of the underlying evidence base for specific CPMs
- The feeling that CPMs were too complicated and detailed for wide deployment and too rigid to be applied realistically in “real world” settings
- Struggles in accessing the CPMs because they were often not embedded into the iCentra clinical workflow
- No standard implementation process to pilot and spread CPMs consistently, with carefully considered implementation strategies to address barriers to use
Consistent with Intermountain' s relentless pursuit of extraordinary care, these findings highlighted an opportunity to improve the adoption and spread of our CPMs with a more aligned approach being led by Clinical Programs but being supported by a coproduction model including Continuous Improvement (CI), the Health Information Technology (HIT) team, and the Implementation Science (IS) team from the Intermountain Healthcare Delivery Institute.
FRAMING AN IMPLEMENTATION APPROACH
The field of implementation science developed out of a need to study “methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice.”4(p1) Implementation science focuses research attention on understanding the barriers and facilitators that impede or enable change at the point of care. Barriers are not limited to the technology but include the protocol itself, as well as the people and the workflow processes that lead to successful care. Such barriers can also extend beyond the point of care to alignment with health care system leadership and to the implementation plans themselves. Once barriers are identified, implementation strategies can be developed and deployed to address the obstacles that prevent high adherence.
Intermountain' s first step toward better standardizing deployment of EBP was to establish guiding principles from the field of implementation science to inform our approach and to guide our design.
The first guiding principle was ensuring clear leadership commitment both vertically and horizontally within the organization, beginning with the Executive Leadership Team and flowing through to the field operations teams, the frontline teams, and support functions impacted by this work. Clear leadership commitment ensures that the efforts taken align with enterprise strategic priorities and that the resources required to effect change are made available to meet the objectives.
Second was ensuring that cross-functional resources were available and committed to evaluating the problem and finding solutions. Health care settings are complex organisms that require dedicated effort in the identification and engagement of collaborators from key functional areas. Team-based approaches with good cross-functional engagement are linked to better outcomes.
Third, while much progress had come through organic approaches to disseminating EBPs, the feedback from the clinical teams suggested the need to build a standardized, generalizable implementation process that could adapt with the needs of each care process. A more standardized approach would ensure representation from all the key functional parties that had a stake in the success of the implementation. A standard approach could ensure that the caregiver, workflow, technology, and intervention protocols were all carefully considered in the implementation. Standardization would also allow for adaptability and the development of playbooks over time as we capture what works best in what setting and pursue scale.
Fourth, successful implementations require selecting the right CPMs to implement. The characteristics of the CPM itself can have a meaningful impact on uptake and adherence and the chance of future success. CPMs that deliver little added value for patients but increase the burden on frontline caregivers will be largely rejected or ignored—and with good reason. The increasing rate of innovations in care coupled with the limitations on both available resources to implement and capacity to manage change suggests the need for a robust prioritization approach to determine what matters most.
The final and perhaps most critical principle was ensuring that the frontline clinical staff were actively engaged in determining the problem and developing sustainable solutions. Engagement by end users in the development of any meaningful change increases the likelihood of success. Given demands on time, it was important that we introduced an engagement approach they felt was purposeful, minimally disruptive, and followed Intermountain's general operating model.
Based upon evidence from the implementation science field, we felt like an approach adhering to these core principles would give us the best likelihood of success in increasing adherence to EBPs.
IMPLEMENTING CARE PROCESSES
Following the results of the survey regarding barriers to CPM usage, Clinical Program leadership in both adult and pediatric care was tasked by executive leadership with selecting and implementing 2 evidence-based CPMs with an expected outcome of high-level caregiver adherence. A cross-functional enterprise team was organized by Clinical Program leadership that included representatives from CI, IS, HIT, and the Clinical Program team. The working team was tasked with 2 objectives: (1) determine the best approach to increasing adherence for the 2 identified CPMs and (2) develop a long-term generalizable approach to increasing CPM adherence for Intermountain. The clinical program that developed the CPM was accountable for achieving the adherence goals.
The working team developed a 5-phase approach to CPM deployment that was approved by leadership. Key phases include:
- Search and Develop. This phase includes the steps required to identify a high-potential evidenced-based practice for certification.
- Certify. This phase includes the steps for certifying the practice or CPM as evidence-based and preparing the proposed CPM protocol for prioritization.
- Prioritize. This phase includes the steps for prioritizing among roughly 20 CPMs that were being considered for implementation and selecting 2 CPMs for deployment
- Spread. This phase includes the steps required to spread the EBPs to a set of pilot sites and then scale to all applicable sites, including the development and testing of implementation strategies.
- Evaluate. This phase includes the steps for evaluating the effect of the implementation strategies on adherence by site and for the system.
The working team had a backlog of existing CPMs that were being considered for the initial selection and deployment. The team developed tools for each Clinical Program to use in assessing CPM readiness for deployment. The Clinical Program presented their CPM assessment and a final selection was made by the Clinical Program leadership with support from Executive leadership. Criteria considered in the selection of the 2 CPMs for the initial pilot work are noted in the Table. The final CPMs selected included the Adult Stroke Care Process model and the Pediatric Minor Head Trauma Care Process model, with both being deployed in the Emergency Departments of Intermountain.
Prioritization Criteria for Selection of Care Process Models for Deployment
|Key leverage points are well defined. A key leverage point is a step in the care process that individually has a significant impact on patient health.
|A measurement system (for compliance with key leverage points) is in place and functioning well.
|There is strong evidence connecting key leverage points to desired outcomes.
|The opportunity to improve adherence to key leverage points is significant from the measured baseline.
|The likely benefits of the planned spread far exceed the costs.
|The leadership team is likely to provide robust leadership.
|All necessary resources are available.
|All health technology challenges can be met.
|The field barriers to deployment are surmountable.
|We have a reasonable implementation strategy.
|If we execute well, the target clinicians are likely to embrace the necessary changes.
With the projects selected, the Clinical Program assigned a separate project leader for each project. The project leader, along with the clinical sponsor and project consultant, represents the team responsible for deploying the CPM in the field. The team also included members of the overall working team from CI, IS, HIT, and Clinical Leadership, to ensure functional resources could be engaged rapidly during the deployment.
Pilot site selection criteria included geographic location (urban/rural), facility size, existing adherence rates, engagement of site-level leadership, and evidence of ability to implement. Variation in these factors was sought across sites to ensure adequate representation of facility needs and capabilities.
To empower the site teams directly to advance adherence, a daily improvement method known as Kata was selected.5 Under the Kata methodology, Kata teams are organized from the frontline teams involved in care with a clear objective in mind—in this case, increasing adherence to an evidence-based CPM. The Kata team uses a weekly improvement cycle to identify barriers to increased adherence and then identifies a specific strategy each week to address the barrier. A weeklong “experiment” ensues where the Kata team performs a test of change and measures their results. Results are reported out weekly in their Kata improvement huddle to their improvement coach. Each week, the Kata team identifies a new barrier and a new implementation strategy to test until the team achieves their stated performance goal. The final working solutions developed by each of the pilot sites are then collected and analyzed for best common practices among the pilot sites. The best practice standards will be laterally deployed to the remaining sites with support from functional leaders. Field response to this approach has largely been positive with good engagement from frontline teams.
ADVANCING EVIDENCE-BASED CARE
Advancing adherence to evidence-based clinical care is an important key component of a learning health system and critical to the quality and safety of the care that is offered to patients by the caregivers and the health care system. Despite this, effective and practical solutions that lead to increased adherence have remained elusive. We have described our work to date, and while Intermountain is early in the spread phase, the results are promising. There is promise in the idea and discipline that focusing on the work delivered by the clinical teams and leveraging implementation science, along with the skills and talents of cross-functional teams including continuous improvement and clinical informatics, may produce more deliberate yet novel approaches to delivering evidence-based medicine.
1. Committee on Quality of Health Care in America and Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
2. Cabana MD, Rand CS, Power NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458–1465.
3. Damschroder AJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Sci. 2009;4:50.
4. Eccles MP, Mittman BS. Welcome to implementation science. Implementation Sci. 2006;1:1.
5. Rother M, Aulinger G. Toyota Kata Culture: Building Organizational Capability and Mindset Through Kata Coaching. New York, NY: McGraw-Hill, 2017.