Adopting best practices is key to improving quality of care, but once those ideal strategies are identified, it can take an agonizingly long time to actually get an organization to start using them consistently. Some healthcare organizations are finding ways to cut down that long introduction period, which can mean achieving improvements years sooner.
Even when the healthcare community settles on best practices for any particular area of concern, it takes an average 17 years from publication of research findings until they are widely used, according to one report. (An abstract of the report is available at: https://bit.ly/2I6OWgI.)
That was way too long for healthcare leaders such as Michael H. Kanter, MD, a research scientist with Southern California Permanente Medical Group, and chair of clinical science and professor at the Kaiser Permanente School of Medicine in Pasadena, CA. Kanter previously was executive vice president and chief quality officer for The Permanente Federation and medical director of quality and clinical analysis for the Southern California Permanente Medical Group.
Kanter and his colleagues looked for ways to implement best practices in months, not years or even a decade. One of the implementation methods Kaiser Permanente uses for best practices is the E-SCOPE (Evidence Scanning for Clinical, Operational, and Practice Efficiencies) system. The program is designed to facilitate the most rapid identification and implementation of new evidence-based practices by using systematic evidence searches to first recognize them, then using accelerated decision-making with Kaiser Permanente to get them in use.
“We scan the literature, systematically looking for practices that will improve quality, reduce costs, improve satisfaction. A lot of organizations have a more passive approach, waiting until their doctors discover something or they hear about it at a quality meeting,” Kanter says. “We try to get at it earlier with a scan that pulls evidence-based abstracts that are reviewed by a group of physicians who determine their initial validity. Then, they are reviewed by senior leadership who determines if the practices have actually been deployed in a system or not.”
Best Practices Deployed Quickly
If they have and the practices seem promising, they are taken to chief stakeholders who would implement the best practices, Kanter says. The changes can involve direct clinical care or operational issues. He recalls one instance in which E-SCOPE identified an article about steam sterilizer practices that were efficient and created a smaller carbon footprint, so they were taken to operating room managers. The practices were soon adopted.
Kaiser Permanente employs a project manager who works with hospital units to encourage rapid adoption once the chief stakeholders accept the changes, Kanter explains. Another example involved weight loss interventions that were shown in 2015 to reduce severity of psoriasis symptoms. Through the rapid implementation using E-SCOPE, the health system offered weight reduction options to 18,000 psoriasis patients in only eight months. (See the related story in this issue for more on Kaiser Permanente’s strategies for rapid implementation of best practices.)
“A lot of the best practices we have already implemented, so we’re looking for the ones we haven’t. With a relatively small resource allocation, we have put in about 25 practices,” Kanter says. “Some of them have been very impactful while the impact of some, like the steam sterilizers, has been relatively modest. But those were relatively easy to do, so the return is still worthwhile.”
To speed the adoption of best practices, Kaiser Permanente does not bother replicating the results of published research or measuring the impact in a small trial implementation, Kanter explains.
“One of thing things organizations do is trying pilots, doing some new practice and then measuring to see if it worked as intended. That takes a lot of resources and can be problematic because you need a control group and have to account for measurement artifacts and bias,” he says. “We don’t try to reprove the evidence if it’s already been published and accepted as legitimate by our stakeholders. That’s a major philosophical change that makes it scaleable.”
Move to Virtual Cardiac Rehab
In another example, Kaiser Permanente found evidence that virtual cardiac rehab works as well as traditional cardiac rehab, which many patients forgo because it is expensive and requires frequent visits to a hospital or clinic. The health system deployed a program that uses remote connections so the patient can participate from home. As a result, the participation level among cardiac patients has greatly increased, Kanter says.
The rapid adoption of best practices depends on clinicians accepting their validity, and Kanter notes that there sometimes can be pushback.
For instance, some leaders may question whether the patient demographics or other factors are different in a meaningful way. The E-SCOPE program tries to minimize those concerns with reviews by clinical leaders who look for those potential issues before recommending adoption of the best practices, he explains.
“There also will be occasions where people just feel overwhelmed by the changes being pushed on them and feel like they can’t take this on right now, even if they don’t dispute the value of the best practices we’ve identified,” Kanter says.
“In that case, we have enough to focus on that we can move on to the next one and look at what we implement rather than getting bogged down in what we don’t. We’ve not allocated a lot of resources to this yet, but we’ve deployed a lot of improvements for our 4.5 million members.”
The E-SCOPE program delivers about 100 abstracts a month for Kanter and his assistant to consider. That’s a lot to keep up with, he says, even though the algorithm was tweaked to narrow the results down to the abstracts most likely to be useful.
“We found that pharmacy and drug therapy are areas in which we don’t have that much opportunity, possibly just because of how our system is structured with very good pharmacists who do a good job of keeping up with improvements there,” Kanter says.
“So we look less thoroughly at drug issues in the literature, and that narrows down the abstracts we have to review. Other systems may have a different experience depending on their own particular strengths.”
The biggest barriers to adopting best practices are time and organizational culture, says Jane Carmody, DNP, MBA, RN, program officer with The John A. Hartford Foundation (JAHF), a nonprofit, nonpartisan organization in New York City that works to improve conditions for the care of older adults in the healthcare system. She previously was chief nurse of a large health system in the Midwest.
“I’m a firm believer that you have to have a process for introducing best practices, or it just won’t work,” Carmody says.
“Particularly in a health system, you will have so many different areas of expertise and specialties, and all of them will be monitoring their areas for new developments and best practices.”
Carmody has seen success with first creating a large interest group of individuals who are seeking to improve care, which should include the chief medical officer and chief nurse.
They help create the urgency that can guide others to a rapid implementation, she says.
“You aren’t going to create change by telling people this is the best way to do it and you need to start doing it this way right now,” she says.
“You have to recognize the influence of the culture and the emotion that can come with change. Some people may feel like everything is new again and they’re novices now, whereas yesterday they were the experts. That can increase their resistance.”
One strategy is to minimize the feeling of change so that people feel more like you are asking them to do what they are already doing in a slightly different way, rather than having them feel like they must do something completely different, Carmody suggests.
It also is important to ensure that the available technology matches and supports what you are asking people to do, she says.
Best practice implementation can be derailed if you push the potential benefits only to have people find that the electronic medical record or other tools make it difficult or impossible for them carry out your instructions.
“Sometimes, if it’s a good idea, you don’t have to push it very hard. People will say, ‘Oh, yes, that makes sense,’ and it will go viral on its own,” Carmody says.
“When that happens, you have to make sure you are prepared to support that implementation and not let that enthusiasm go to waste.”
Networks Have an Advantage
Hospital networks and other cooperating facilities have a leg up when it comes to discovering and implementing best practices, notes Troy Polan, chief technology officer with Excelera, a specialty pharmacy network based in Minneapolis, MN.
Polan leads data collection for the 23 health systems that are part of the Excelera network.
Like many hospital networks, Excelera members have a formal structure of communication, committees, and collaboration to both identify best practices and implement them systemwide, he says.
“One benefit is that best practices are not unique to one facility ... because [facilities] are collaborating on them,” Polan says.
“An example is how in the last six months, there have been new migraine meds coming to market, so we’ve had a few members who thought we should get together to talk about protocols and exactly how to manage these medications in certain populations,” he says.
We have a few members who are working to sort that out and share it with the rest of the network.”
Rapid adoption of the best practices is baked into the process, Polan says.
“By working together rapidly, the implementation of best practices can be a lot more dynamic than perhaps seeing a presentation by someone and trying to figure out how to do this,” he says.
“Because there is a dialogue and the consideration of how other groups will implement this,” Polan says, “there is an inherent dynamism that you don’t get when you just present an idea to people and they have to determine how that process that worked somewhere else also can work for them.”
Organizations tend to have more trouble implementing broader, wide-ranging best practices, Polan notes.
The narrower the focus, the more rapidly the best practices can be absorbed into an organization’s operations, he says, whereas expansive cultural changes can take much more time.
“It’s hard to change a lot of things at once,” Polan says.
“An incremental change or a well-defined change in a limited portion of your organization usually can be implemented much more quickly in a healthcare setting. As organizations become more receptive to learning from each other, there is great potential for improvement across the entire country and the healthcare community.”
- Jane Carmody, Program Officer, The John A. Hartford Foundation, New York City. Phone: (212) 832-7788.
- Michael H. Kanter, MD, Research Scientist, Southern California Permanente Medical Group, Pasadena, CA. Phone: (510) 267-7449.
- Troy Polan, Chief Technology Officer, Excelera, Minneapolis. Phone: (612) 293-0378.
