By Naomi Kuznets

Clinical practice guidelines, research literature and involvement in benchmarking activities

When considering how to achieve significant sus- tained improvement, you may wonder who deter- mines what is appropriate and sets the bar. The very idea that 100 percent compliance is achievable may make you suspicious.

In many cases, national medical specialty societies and others develop guidelines from evidence and expert opinion in order to provide recommendations for improving health care delivery. An important part of developing the guideline recommendations is defining the appropriate patient populations. Once these are defined, some guidelines may suggest that 100 percent compliance with recommendations is an appropriate short-term performance goal.

When you see 100 percent compliance recommendations in guidelines,

you must consider what barriers (and possible solutions) there are to 100 percent compliance. This information may be contained within the guidelines themselves or in research literature developed from the measurement of real-world compliance with guidelines. Here is an example.

Compliance With Antibiotic Timing Guidelines

If a prophylactic antibiotic is recommended (depending on the type of procedure being performed and the patient) in Centers for Disease Control and Prevention (CDC) guidelines, the recommendation is usually very specific about timing the administration of most antibiotic prophylaxes within 60 minutes of first incisions.

Think rationally about your organization’s ability to comply with this guideline. For example, what happens to antibiotic timing when a case runs long and the next patient has already received the recommended antibiotic prophylaxis because you don’t want to push the antibiotic too fast, but you do want to have the patient ready when the surgeon is ready?

A search of the research literature, using the US National Library of Medicine Medline (www.ncbi.nlmnih.gov/sites/entrez?db=pubmed 5/10/2010) and the search term “antibiotic timing compliance,” yields a wealth of information about issues associated with compliance and what a realistic goal (bench- mark) may be. Look in the search results for research that appears to most closely resemble your setting and ones that can give you ideas that may help you improve.

What About When There Are No Relevant Clinical Practice Guidelines Or Research Literature?

Let’s consider a wait time example. There aren’t clinical practice guide- lines to indicate what an appropriate wait time goal is, and peer-reviewed research literature offers little to nothing in the way of relevant benchmark information. Here is where external benchmarking can provide guidance.

For Organization A, 45 minutes met and exceeded their patient wait time performance goal. However, Organization A has now become involved in an external benchmark- ing study and sees that some peer organizations (B, C and D) have average wait times of 20 to 25 minutes. Without external bench- marks, Organization A would not know if an average wait time shorter than 45 minutes is realistic, or how much shorter is achievable. Knowing that Organizations B, C and D have average wait times of 20 to 25 minutes suggest that this is a goal for Organization A to try to accomplish.

If further information is gathered from Organizations B, C and D regarding the processes they use to move patients from check-in to the exam, pre-op area or procedure

room, Organization A can try these to help shorten their own patients’ wait times.

This is an excerpt from Quality Improvement Insights, a compilation of -QI focused topic whitepapers published by the AAAHC Institute for Quality Improvement. Quality Improvement Insights is one element in the Institute’s QI Toolkit that also includes Quality Improvement and Benchmarking: A Workbook of Strategies and Tools for Success, and Innovations in Quality Improvement Compendium. Each of the tools includes examples and commen- tary designed to guide organizations step-by-step through the AAAHC    “ten elements” of QI.


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