(Chest. 2000;118:33S-39S.)
© 2000
American College of Chest Physicians
Provider Education To Promote Implementation of Clinical Practice Guidelines*
Judith K. Ockene, PhD, MEd and
Jane G. Zapka, ScD
*
From the Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, North Worcester, MA.
Correspondence to: Judith K. Ockene, PhD, MEd, Division of Preventive and Behavioral Medicine, University of Massachusetts Medical School, 55 Lake Ave, North Worcester, MA 01655; e-mail: Judith.Ockene{at}umassmed.edu
 |
Abstract
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Study objectives: Although the interest in and
promulgation of clinical practice guidelines have significantly
increased in the past 2 decades, concern exists about their actual
implementation. This article focuses on one strategy to encourage
guideline implementation at the clinician level: clinician education.
The objectives of the article are to review educational strategies, to
consider them within the context of complementary strategies
carried out at the organizational and clinic setting levels, and to
outline challenges and recommendations for clinicians’ continuing
education.
Methods: Experience and data from
relevant randomized clinical trials within an educational framework are
reviewed.
Observations: Implementation of clinical
practice guidelines requires a variety of skills, including assessment,
appropriate delineation of a treatment and monitoring plan, patient
tracking, and patient counseling and education skills. Continuing
education strategies must reflect the content and teaching methods that
best match the learning objectives. The pressures of current-day
practices place limits on the resources, particularly clinician time,
that are available for continuing education. Organizational resources
must be committed to build the complementary supportive systems
necessary for improved clinician practice. In addition to physicians,
education must be directed at nonphysician clinicians, office staff,
and administrators who also are responsible for guideline
implementation.
Conclusions: To meet the challenges of
developing clinician motivation, balancing competing demands, and
treating patients with complex medical conditions, all within time
constraints, clinical leaders need to design education activities that
have leadership support, reflect compelling evidence, use multiple
strategies and teaching techniques, and engage learners in skill
building and problem solving.
Key Words: implementing guidelines • medical education
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Introduction
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Despite
widespread dissemination of clinical practice guidelines, adherence to
them during patient care is often low, making this a major research,
clinical, and public health concern. For example, even though the
Agency for Health Care Policy and Research (AHCPR) smoking cessation
guideline1
published in 1996 has been widely disseminated,
the current level of physicians’ implementation of it in real-world
settings is less than optimal. Physician reports indicate that 
50%
of smokers are counseled for cessation during office
visits,2
although a larger percentage are at least advised
to stop smoking.
Implementation by clinicians of clinical practice guidelines can be
influenced in many ways. These include education, financial incentives,
management strategies (such as collection and feedback of comparative
data to clinicians, and cueing via computerized medical records),
performance expectations or benchmarks, and alteration of structural
aspects of the clinical environment (convenient availability of
specialists, including nonphysician personnel).3
This
article focuses on one strategy: clinician education.
Given the significant positive primary and secondary prevention effects
that provider-delivered interventions can have on patients’ health
behaviors such as smoking and health conditions such as asthma, it is
important to consider educational interventions to increase the rate of
use of evidence-based guidelines (Fig 1 ). Although the interest in and promulgation of clinical practice
guidelines have greatly increased in the past 2 decades, concern
remains about the actual implementation of the guidelines at the
organizational, clinical setting, and individual clinician levels. In
addition to physicians, there are other providers (eg,
nurses, psychologists, respiratory therapists, nutritionists, and
health educators) who also have responsibility for different levels of
intervention intensity, as included in guidelines. The challenge is
multilevel and multidisciplinary.
In this article, we will address the following:
- Educational strategies (eg, lectures, workshops,
electronic technology, and academic detailing) that can be used to
promote implementation of guidelines.
- Education in the context of other activities for promoting guideline
implementation.
- Challenges and recommendations for providing adequate education to
promote guideline implementation.
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Educational Interventions
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Education focusing on the provider is a major method used to
affect patient care and improve outcomes. The choice of strategy,
teaching technique, and content of an educational program needs to
reflect clear educational objectives. These objectives include
improving awareness of guidelines and the evidence behind them; beliefs
about appropriateness, effectiveness, and feasibility; and skills
needed to implement guidelines to maximize effectiveness. Grimshaw and
colleagues4
5
have separated educational strategies into
two types: dissemination strategies, designed to influence
awareness, knowledge, and attitudes toward guidelines and their
recommendations; and implementation strategies, designed to
improve adherence to recommendations, turning changes in knowledge and
attitudes to changes in practices.
There is considerable overlap in the types of activities and strategies
that can be used to affect knowledge, awareness, attitudes, and skills.
However, activities designed to affect knowledge and awareness are more
informational, while those needed to affect attitudes and skills
require interaction and opportunities to practice skills. The
traditional continuing medical education formats of lectures, grand
rounds, or brief noon/morning reports are good for increasing
awareness, but have limited effectiveness in affecting
practice.6
7
Electronic dissemination and print media also
provide knowledge and increase awareness, but do little to affect
attitudes, skills, and practice. Workshops offer opportunities for
interaction and multiple teaching and learning strategies, but require
more resources and clinician time than does information dissemination.
World Wide Web-based interactive curricula, interactive videos, and
other electronic technologies can be used8
for
facilitating skill building. Development of this technology is on an
upward spiral and is likely to enhance our ability to provide
interactive experiences.
Academic detailing7
is an educational strategy that can
provide interaction and help address the challenge of the limited time
available to clinicians for educational activities. Educators visit the
practice site to provide face-to-face education in an interactive mode.
It has been used successfully to affect drug-prescribing
practices.7
It also has been used to provide smoking
intervention training to physicians.9
In the latter
example, office staff were included in the training to help them set up
the practice to facilitate the use of appropriate treatment. Since
academic detailing was one of several educational strategies for
facilitating smoking treatment, it was not possible to determine its
efficacy when used alone.
Several techniques are available for teaching and practicing skills.
Providers can practice and learn interventions using role playing,
patient simulators, and discussions of clinical case examples
(eg, decision making about pharmacotherapy for a patient
with a comorbid condition).6
10
Enough time must be set
aside to allow for skill building. However, even in the grand
rounds-type of presentations or 1-h conferences, the more we can attend
to discussions and actual experiential learning, the more likely it is
that the physicians, nurses, respiratory therapists, and other
providers will develop skills and go home and use some of
them.10
One example is the use of brief exercises in which
the conference participants are grouped into dyads to engage in role
playing, followed by a discussion of how the exercise went.
Examples of the use of educational techniques to facilitate the
development of counseling skills and of their impact on physician
skills are available in three National Institutes of Health-supported
randomized clinical trials conducted at the University of Massachusetts
Medical School.11
12
13
In each of these studies, physicians
were taught through 2 h of lecture, modeling, role-playing, and
discussion. They significantly improved their counseling
skills,11
12
13
and implemented the practices in their
offices when they were cued to do so,14
15
and patients
significantly decreased their smoking (Fig 2
),16
dietary fat use (Table 1
),17
and alcohol use (Table 2
),18
respectively.
View this table:
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Table 1. WATCH 12-mo Changes in Saturated Fat Intake, Total
Cholesterol, LDL, and Weight by Treatment Condition
(n = 1,278)*
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The content of the educational activity also is important. Too often
the stress is on biomedical "fact." While clearly important, this
is insufficient for facilitating change in practices. The choice of
content and teaching strategy is particularly important given the
paradoxical view of patient counseling held by many clinicians. That
is, counseling skills are viewed as "simple and natural," yet they
take too much time and may be ineffective. Frank discussion about
perceived effectiveness and feasibility should occur, led by respected
champions or opinion leaders.19
Information needs to be
provided about the evidence that justifies the guideline; how
implementation can occur successfully, including the use of office
reminders and patient-tracking systems; and any billing procedures
needed to facilitate reimbursement. Encouraging the clinician’s role
in organizational efforts to alter systems and resources in his or her
organization is usually crucial.
Guidelines often recommend different levels of treatment intensity,
depending on the patient’s needs. The AHCPR smoking cessation
guideline1
suggests that physicians can deliver a
continuum of interventions ranging from asking about smoking and
advising the patient to stop, to providing different levels of
assistance in order to help the patient stop smoking (Table 3
).1
Another example of a range of intensity of treatment
recommended can be found in the National Heart, Lung, and Blood
Institute guideline for the diagnosis and management of asthma (Table 4
).20
In both the smoking and the asthma guidelines,
physicians are expected to counsel and provide education to patients.
Depending on the intensity of assistance provided, different levels of
skill and therefore of training are needed. The challenge is to design
engaging educational strategies that illustrate effective skills at the
appropriate level within realistic clinical situations. Although much
of the training and education can be generic to any setting and any
patient population, there needs to be opportunities for clinicians to
apply the information and training to their own particular patient
populations and settings. This can be done through clinical case
examples, discussion, and role playing.
In summary, to be effective, education must be specifically tailored to
the knowledge, attitudes, and skills needed for implementing the
guideline; the intensity of treatment expected of the provider; the
special needs of particular patient populations; and the context and
setting in which the intervention will be delivered.
|
Education in the Context of Other Activities for Promoting
Guideline Implementation
|
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As noted earlier, clinician education is only one strategy to
enhance and encourage clinician behavior. Education must be considered
and implemented within the context of other interventions at the
policy, organizational, and clinical setting levels. Interventions to
change provider behavior can be grouped broadly into three types:
organizational policy; clinical systems and procedures; and provider
education (Fig 1)
.10
A model developed by Green and
Kreuter21
indicates that for providers to use the
information they have, strategies are needed that enable the
clinician’s implementation of recommended clinical processes and that
reinforce their use of guidelines and practices. Clinical systems and
procedures, including patient tracking and provider reminders, help
clinicians implement guidelines and change the way they practice.
Without these systems, implementation of guidelines will not happen. In
our studies, we have demonstrated that while clinician education is
necessary, it is not sufficient; systems must be added to education in
order to change clinician behaviors.14
15
We used
patient exit interviews22
to determine how many counseling
steps physicians were using in our National Heart, Lung, and Blood
Institute-funded Worcester Area Trial for Counseling in Hyperlipidemia
(WATCH) study.12
14
WATCH was a randomized clinical trial
designed to test the effect of the use of physician-delivered
counseling and office systems, including patient tracking and physician
reminders, on patients’ saturated fat intake and, subsequently, blood
cholesterol levels and weight. Clinical sites in a closed-panel health
maintenance organization (HMO) were randomly assigned to usual
care (condition 1), training (condition 2), or training plus reminders
(condition 3). As seen in Table 5
, education alone (condition 2) did not increase performance of
intervention steps implemented by physicians beyond what the usual-care
physicians (condition 1) did. However, training-plus-reminder systems
(condition 3) did significantly affect physician practices. Likewise,
reminders alone are not as effective as reminders plus
education.23
Organizational policies and norms also provide a climate by which
consideration and appropriate application of guidelines are encouraged
and expected.24
These include promotion of
quality-assurance activities, performance accountability, and support
for staffing patterns and management information systems that enable
and reinforce clinician implementation of guidelines and encourage
facilitation and maintenance. Additionally, design and application
systems and procedure strategies in the practice setting that remind
the provider to intervene and track the progress of patients are
crucial to maintenance of clinician behaviors.25
Administrative and personnel strategies such as feedback and
performance measures are needed to reinforce the use of guidelines.
These strategies will be discussed in depth in another article in this
issue. Because systems, reminders, and incentives are necessary, it is
important to include information about these strategies in any
educational activity implemented to promote guideline use.
|
Challenges to Providing Adequate Education To Promote Guideline
Implementation
|
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If we want clinicians to apply their education about
implementation of specific guidelines to patient care, then we need to
systematically investigate and improve the multiple approaches that
enable and reinforce the practices and skills learned. The challenges
to adequate education for guideline implementation in the health-care
setting, however, are many (Table 6
). A basic challenge is that organizational leadership and clinicians do
not all "buy in" to the need for a particular intervention, or do
not know how effective the intervention can be. Frequently, the first
question asked by clinicians is, "Why should I learn this?" Without
buy in, there is little likelihood that the new practice patterns will
be tried and maintained. To meet this challenge, as noted above, we
need to educate and work with administrative and clinical leaders to
enhance their understanding of how important leadership and
organizational commitment and expectations are to the ultimate goal of
improved care processes and patient outcomes. We need to discuss the
concerns and needs of the clinicians, perhaps using opinion leaders to
facilitate discussion. With an increased understanding of their
concerns and needs, we are better able to tailor the interventions to
their setting.
View this table:
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|
Table 6. Challenges to Providing Adequate Education of Health
Care Providers for Promoting Guideline Implementation
|
|
Even when clinicians buy in to the need for the intervention, learn
what they need to know, and are cued to deliver it for a particular
problem behavior or health condition, other challenges interfere with
the performance and delivery of appropriate treatment. There are
competing demands for patient education, counseling, and treatment.
Patients often present with complex, multiple problems, and clinicians
are constantly exhorted to educate their patients about many things,
including smoking, alcohol consumption, diet, asthma management, and a
large number of other medical and lifestyle behaviors. How do we
organize and coordinate services so that clinicians can put them
together to care for their patients in a sensible and efficient way,
and at the same time meet their patients’ acute care needs? We need to
help clinicians work in efficient ways with patients who have multiple
problems. Guidelines that coordinate treatment for multiple health
behaviors and conditions need to be developed to do this. Another
potential solution for improving outcomes with patients with multiple
problems is the use of multiple providers for patient care. One
individual can coordinate the care of the patient, and several
disciplines can assist in the patient’s management. An excellent
example of the value of a team effort is the Asthma Co-Management
Program developed by Dr. Richard Irwin and his colleagues in the Asthma
Clinic, and a behavioral psychologist at the University of
Massachusetts Medical School. This program includes an excellent office
management system and a multisession group program for patients who
have asthma. The group program includes asthma education and exercises
to enhance the development of disease self-management skills. Smoking
treatment and stress management also are included. It has been very
successful in helping patients manage their asthma and in helping the
physicians efficiently deliver the level and type of care recommended
in the asthma diagnosis and management guidelines.20
Since
nurse-assisted interventions in collaboration with physicians do have a
significant effect1
26
on both the physician’s time and
the patient’s care, our educational agenda must include learning
opportunities for nurses and other clinicians. In a later article, we
will hear more about this from Dr. Jack Hollis.
Another way to deal with the limited time availability of the physician
is to allocate resources that encourage the involvement of support
staff to set up the systems needed for implementation of guidelines.
When our team conducts educational programs, we emphasize the
importance of participation by a support staff member in the training
session. That person can go back to the setting and develop an office
system to support and facilitate intervention in the practice.
Alternatively, we need to consider providing the practice with
technical assistance to help providers set up a system that fits for
them.
Another challenge is that the demands of the modern-day health-care
setting, where every minute and every penny counts, is reflected in the
limited time available to physicians, nurses, and other clinicians to
devote to educational opportunities or intervention. How do we organize
and coordinate continuing education programs so that clinicians are
able to fit them into their busy schedules in order to learn the
guidelines and acquire appropriate skills? Some combination of
interactive electronic technology and face-to-face training such as
with workshops and academic detailing may be a possibility. We do not
have any "magic answers," but it is a question we must consider. In
this tumultuous era of changing health systems, organizations and
clinics frequently feel hard-pressed to allocate time for structured
continuing education.27
However, this investment is
essential if practice patterns are to change and improved outcomes are
to be realized. Administrators on the clinical and policy levels need
to be educated and motivated to buy in to the need for clinicians to
have educational opportunities so that they are willing to allow the
time for education.
Although there is a limited amount of time that clinicians can give to
continuing education, when educational events are supported by the
practice or by the HMO or other plans, clinicians are likely to attend
them. In the WATCH study,12
14
there was 100% attendance
at the 3-h training program, with 100 physicians attending. There were
four time choices for the training sessions, but, more importantly, the
HMO administration supported it, signaled physicians that it was
important, and allowed the physicians time for it. Teaching providers
how to enlist organizational support is an important educational
component.
|
Summary
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Educational programs that promote the implementation of
evidence-based guidelines by clinicians will increase the quality of
patient care. Programs are needed for physicians and nonphysician
clinicians and office staff. An educational program should be planned
with clear objectives; be structured with adequate time, materials, and
facilities; and have the endorsement from organizational leadership.
The strategy, teaching techniques, and content must be appropriate for
the objectives of the program and the audience. Skill building requires
more interactive strategies then does information dissemination. We are
starting to see new creative applications of electronic technology in
continuing medical education. Case scenarios and feedback from
experts make computer courses more appealing and less "fact
focused." We must continue to search for creative ways to engage
clinicians, using interactive techniques to help them build the skills
needed for patient education, counseling, and treatment.
|
Footnotes
|
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Abbreviations: AHCPR = Agency for Health Care
Policy and Research; HMO = health maintenance organization;
WATCH = Worcester Area Trial for Counseling in Hyperlipidemia
|
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TOP
Abstract
Introduction
