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Adherence to Clinical Practice Guidelines Improves Care for Patients at Ontario Shores

Rationale / Objectives

Ontario Shores Centre for Mental Health Sciences (Ontario Shores) is a public teaching hospital specializing in comprehensive mental health and addiction services for those with complex, serious and persistent mental illness. Ontario Shores’ mission is to provide leadership and exemplary mental health care through specialized treatment, research, education and advocacy. In order to align practices with our mission, Ontario Shores committed to the systematic implementation of clinical practice guidelines (CPGs) over a five-year period for the assessment and treatment of our patients. In April 2014, the first set of guidelines, for the assessment and treatment of Schizophrenia, was launched for all inpatient units. The primary goals were to: 

  • Improve patient care by offering the full spectrum of tools and treatments recommended by evidence-based guidelines;
  • Increase clinician adherence to clinical practice guidelines; and
  • Utilize the electronic medical record (EMR) database to track adherence to practices and provide meaningful feedback to physicians and clinical managers.

 

Project/Program Description & Major Achievements

Ontario Shores considered CPG implementation as an opportunity to become a data driven organization, using clinical measures to drive quality improvement and enhance outcomes for service users. Following implementation of an Electronic Medical Record (EMR), it was determined that there were inconsistencies in evidence-based practices in the provision of mental health care. Senior Management decided to implement CPGs in order to consistently integrate evidence-based care and standardizeworkflows organization-wide, thus allowing opportunities for evaluation and improvement. The first CPG to be implemented was the assessment andtreatment of Schizophrenia on inpatient units given that it was the most common illness for Ontario Shores patients. Over a twelve month follow-up period, adherence to polypharmacy, metabolic monitoring, and referral to Cognitive Behavioural Therapy for Psychosis (CBT-P) were increased by 5.8%, 51.0% and 74.8%, respectively. Through carefully designed decision support, the system is now fully compliant with the National Institute for Health and Care Excellence (NICE) CPGs for the assessment and treatment of Schizophrenia, which has led to improved patient care and both direct and indirect cost avoidances.  

Lessons Learned

Feedback provided via electronic dashboards was an important contributor to increased adherence. Strong engagement with physicians and interprofessional clinicians was important to success, with high levels of transparency and justification of processes required to support physician buy-in. Involvement of Clinical Informatics to develop structured templates, order sets, clinical panels, decision-support and clinical dashboards was essential to promote adherence and to provide relevant feedback for improvement. However, we learned that attention must be paid to non-information technology components as well. Clinical dashboards were useful for disseminating adherence results to clinicians, but it was challenging to get them to sign in to view results. Additionally, it was noted that some important point of care staff did not have access to the dashboard due to the limited number of software licenses. We have determined that 100% CPG adherence is neither feasible nor optimal, as the clinical presentations treated at Ontario Shores are complicated and all pieces are not necessarily clinically indicated for all service users. 

Further Description

Ontario Shores is located in Whitby, Ontario, Canada has 15 specialized inpatient units and extensive outpatient and community services, serving a total regional population of approximately 2.8 million. The organization is staffed by approximately 1,300 employees with 326 inpatient beds (servicing over 15,000 patient days annually), and approximately 60,000 annual outpatient visits. An integrated electronic environment was seen as an opportunity to implement relevant decision support tools to reduce unnecessary variability in clinical practice. Discrete data elements could be captured to track adherence to best-practice recommendations, ensuring improved adherence to guidelines. The CPG working group leads developed an eight-step framework (and used the AGREE tool for Schizophrenia guideline assessment) based on project management principles. The NICE CPG scored the highest using this tool so was selected for implementation. A clinical algorithm was developed and integrated into workflow and a gap analysis was undertaken by a multidisciplinary team. Working groups were developed and reported to a steering committee composed of stakeholders from across the organization. A modified Delphi process was used to select process adherence measures and patient outcome measures which were all evaluated using National Quality Forum criteria: importance, scientific acceptability, feasibility, usability, and related and competing measures. A project charter was developed based on templates from best-practices in project management and guided the overall development and implementation of the CPG. Informatics was included in all planning activities from the onset of the project to ensure that technology was leveraged to enable successful CPG implementation. Current and future-state work-flows were documented using process maps. Decision documents for service realignment were created by clinical working groups to outline options forresource re-allocation for the purposes of operationalizing the guideline - the project was required to remain cost neutral. Extensive clinical decision support was embedded within the EMR system to promote CPG adherence. Rules were built within the system to automatically trigger specific interventions and orders when clinicians entered certain elements in their documentation templates. Electronic clinical dashboards were created and regularly pushed out to clinicians and administrators to show adherence to CPG recommendations compared to hospital averages. Online tools were developed for staff education to increase awareness of the CPG and aid in the transition. 

Major Achievements

Compared to baseline (March 2014), at 12-month follow-up (March 2015), there was a 5.8% increase in adherence to monopharmacy, a 51.0% increase in adherence to metabolic monitoring, and a 74.8% increase in adherence to CBT-P referrals. However, adherence to metabolic monitoring was the only metric that was at its highest level in March 2015. Adherence to monopharmacy peaked in November 2014 at 62.7% (22.6% increase) and adherence to CBT-P peaked in December 2014 at 13.1% (130.0% increase). Increased adherence to CPGs shows that Ontario Shores’ patients are receiving evidence-based care more often now compared to before implementation. While implementation of metabolic monitoring had no direct cost-savings for Ontario Shores, it does impact long-term overall patient health, reducing the incidence of cardiovascular disease and type 2 diabetes and their complications, hence, reducing the overall economic burden on the health care system. While the initial cost of the CPG implementation was $695,215 (in-kind staffing, EMR software licensing, training), the twelve-month reduction in antipsychotic costs due to reduction in polypharmacy was $12,240. Longer-term cost savings can be anticipated due to improved processes and outcomes of care for this population. Other CPGs are planned to be implemented in the future using this model.

Metric

March 2014

March 2015

Details

Polypharmacy CPG adherence rate

53.1%

58.9%

*See original case study for further details

Metabolic monitoring CPG adherence rate

37.3%

88.3%

CBT-P referral CPG adherence rate

6.5%

81.3%