JCAHO Clinical Guidelines for the Emergency Department

Clinical Guidelines

JCAHO 2004 Clinical Practice Guidelines

Joint Commission on Accreditation of Healthcare Organizations Comprehensive Accreditation Manual for Hospitals Proposed Changes to the Standard for the Use of Clinical Practice Guidelines

Please note that standard numbers are those for the 2004 standards

The proposed new standard language is represented by underlining; language or expectations to be eliminated are indicated by ~~strike-through~~.

The proposed new standard, PI.2.21, would replace the existing CAMH standards (LD.1.10 through LD.1.10.3 in 2003; LD.5.10 through LD.5.40 in 2004)

Standard PI.2.21

Clinical practice guidelines are used for designing or improving clinical processes.

Rationale

Clinical practice guidelines have been used to improve consistency in the evaluation and treatment of patients having a specific diagnosis, condition, symptom, or risk factor, or who are undergoing a high-risk procedure. Clinical practice guidelines are found in the literature under many names: practice parameters, practice guidelines, patient care protocols, standards of practice, clinical pathways, care maps, and other descriptive names. In all cases, guidelines should be based on evidence, or in the absence of evidence, expert consensus, and efficacious and effective for defined patient populations or services.

Elements of Performance for PI.2.21

1. At least annually, at least one clinical process is selected for improvement by the application of a clinical practice guideline.

2. The clinical process selected for improvement is chosen based on demonstrated unfavorable variation in an important clinical process (i.e. a process having significant impact on the quality or safety of patient care), and/or on the potential for a significant favorable impact on the quality or safety of patient care.

3. A guideline is chosen based on evidence, or in the absence of evidence, expert consensus.

4. The guideline is reviewed and, as necessary, revised by the practitioners who will apply it in patient care situations, and by those responsible for its implementation.

5. The appropriate clinical and administrative leaders approve the revised guideline prior to its implementation.

6. Once implemented, variations in the application of the guideline and the outcomes of the process are periodically evaluated, and the revised guideline is modified, if indicated.

For the purpose of education – not as requirements, the following would be placed in a highlighted area next to the standard

A clinical practice guideline describes the processes found by experts to be effective in evaluating and/or treating a patient who has a specific symptom, condition, diagnosis, or risk factor, or who is undergoing a high-risk procedure. The use of clinical practice guidelines has the potential to improve the safety, quality, and value of health care or the health status of patients through:

• Assisting a practitioner and patient in making appropriate decisions about the prevention, diagnosis, treatment, and management of a condition, and/or about the patient’s rehabilitation.

• Improving the utilization of specific health care services by correcting both under utilization and over utilization.

• Improving the effectiveness of specific health care services.

• Reducing undesirable variation that can contribute to the risk of medical or health care error when a specific health care service is provided.

To be effective in improving the safety and/or quality of health care, a clinical practice guideline should be:

• Based on evidence, or in the absence of evidence, expert consensus.
• Periodically reviewed and, as indicated, revised based on new empirical studies and/or changes in expert consensus.
• Adapted, as appropriate, to the specific patient populations served by the health care organization.
• Approved by appropriate clinical and administrative leaders in the organization.
• Disseminated to the practitioners and other staff who will apply the guideline in patient care.
• Implemented by practitioners and other staff.
• Supported through changes in the organization’s systems, such as information management processes and equipment management processes.
• Monitored in order to evaluate its effectiveness and identify variation in its application.
• Modified, as appropriate, based on analyses of the results of the monitoring.

All possible exceptions to the application of clinical practice guidelines cannot be addressed, due to differences in each individual’s physiology, pathology, response to interventions, or preferences. Therefore, some variation in the application of most clinical practice guidelines is clinically appropriate, and for that reason, expected. Variation in the application of a guideline, including the rationale for and the results of the variation, should be recorded and evaluated in order to:

• Identify potential revisions in the guideline that would improve its usefulness and effectiveness.
• Identify clinical practices at variance with the guideline that could be improved.

Clinical practice guidelines applicable to a wide range of clinical services are available. A useful source of information about available guidelines is the National Guideline Clearinghouse, which is accessible on the internet at www.guideline.gov.

Standards for the Role of Leaders in the Use of Clinical Practice Guidelines

These standards do not require the leaders of the hospital to use clinical practice guidelines; rather they provide a framework for developing and using criteria when considering and reviewing available guidelines for the services and care provided in the organization. Clinical practice guideline describes the processes used to evaluate and treat a patient having a specific diagnosis, condition, or symptom.

Clinical practice guidelines are found in the literature under many names: practice parameters, practice guidelines, patient care protocols, standards of practice, clinical pathways, care maps, and other descriptive names. In all cases, "guidelines" should be evidence-based, authoritative, and shown to be efficacious and effective within defined patient populations or services.

How successful a hospital will be with implementation and ongoing use clinical practice guidelines depends upon processes used by the organization to review, revise, and implement the guidelines. The approach used by leaders of hospitals to the following activities will either enhance or deter the use of clinical practice guidelines.

• A multi disciplinary group including a mix of leaders and those health care providers who are expected to implement the guidelines thoroughly review the guidelines to adapt them to the community, needs of the patient population, and resources of the hospital;

• Leaders from both management and clinical areas of the hospital are involved to ensure that appropriate clinical and financial resources will be available to properly implement clinical practice guidelines;

• Any clinical practice guideline used must anticipate and capture variance. There needs to be a process for identifying why the variance occurred or why the guideline was not used (and such analysis is essential to the refinement of the guideline); and

• Performance measures need to be developed as part of the review and revision process of clinical practice guidelines. Performance measures which accurately fit the guidelines being used will give the hospital the ability to better monitor process and outcomes related to using clinical practice guidelines.

Selection of clinical practice guidelines is a criteria-based process and numerous guidelines applicable to a wide range of clinical services now exist. (See the Clinical Practice Guidelines section of

the "Suggested readings and other resources" found at the end of this Leadership chapter.)

A guideline provides an effective way to improve process(es) by reducing variance; yet in any given use, variation must be anticipated and managed. By not managing variance, ie, not capturing and using the rationales for instances of variance or noncompliance with the guideline, practitioner support is lost (eg, guidelines are viewed as "cook-book" medicine). The capacity to refine the guideline in a timely fashion is diminished, and the ability to produce educational products for all constituencies using or affected by guidelines can also be diminished.

Therefore, the following standards provide a framework for the leaders of the hospital to

• define or use published criteria for selecting clinical practice guidelines;

• use implementation criteria for guidelines, including the steps and changes or variations needed to encourage use, dissemination, and implementation of chosen guidelines;

• involve all appropriate parties in discussions;

• review and approve selected, modified guidelines to fit the patient populations served by the hospital; and

• evaluate patient outcomes related to use of clinical practice guidelines in order to improve pertinent processes.

Involved leaders of the hospital may include physicians and other health care professionals, senior administrative staff, and representatives of the governance authority.

Standard

LD.5.10 Clinical practice guidelines are considered for use in designing or improving processes as appropriate.

Intent of LD.5.10

Clinical practice guidelines provide a means to improve quality, enhance appropriate utilization of health care services, and enhance the value of health care services. Clinical practice guidelines assist practitioners and patients in making clinical decisions on the prevention, diagnosis, treatment, and management of selected conditions.

Clinical practice guidelines are also used in designing clinical processes or checking the design of existing processes. Clinical practice guidelines addressing these areas are identified and considered by the leaders for implementation.

The hospital’s leaders consider such sources as the Agency for Health Care Policy and Research (AHCPR), professional medical societies and physician organizations, professional health care

associations, and local organizations.

Standard

LD.5.20 When clinical practice guidelines are used, the hospital leaders identify criteria for their selection and implementation.

Intent of LD.5.20

The hospital’s leaders set criteria to guide the selection and implementation of clinical practice guidelines that are consistent with the organization’s mission and priorities.

Leaders also consider the steps and changes or variations needed to encourage use, dissemination, and implementation of chosen guidelines throughout the organization. This includes staff communication, training, implementation, feedback, and evaluation. Methods of dissemination and implementation can include manual and/or computer designed tools.

Implementation criteria for clinical practice guidelines consider the following.

• Modification(s) necessary to support specific level or locus of guideline implementation;

• Mechanisms for anticipating, evaluating, and learning from variation in guideline(s) compliance;

• Recommended or selected measures pertinent to decisions points, outcomes, and variations relating to compliance;

• Whether the guidelines can assist the practitioner in making decisions about appropriate health care for specific clinical circumstances;

• Whether the guidelines are based on current professional knowledge and are reviewed and revised periodically; and

• Mechanisms for disseminating information about implementation of selected guidelines.

Standard

LD.5.30 Appropriate leaders, practitioners, and health care professionals in the hospital review and approve clinical practice guidelines selected for implementation.

Intent of LD.5.30

Identified clinical practice guidelines may be found suitable for use as written or they may need to be modified by the physicians and other health care professionals who will use the practice guidelines. To increase the success of the implementation of guidelines, they should be reviewed by the providers using

them, revised or adapted as necessary, and approved by appropriate leaders. Modifications of the clinical practice guidelines may be necessary to form a consensus on appropriate clinical or medical practice or to adapt them to the specifications of the hospital.

Once the clinical practice guidelines have been reviewed and approved by physicians and health care professionals, they are approved by appropriate leaders prior to implementation.

Standard

LD.5.40 Leaders evaluate the outcomes related to use of clinical practice guidelines and determine indicated refinements to improve pertinent processes.

Intent of LD.5.40

Once approved and implemented, the practice guidelines are monitored for their effectiveness in the hospital. The hospital’s leaders ensure that the outcomes of clinical practice guidelines are evaluated and refinements are determined, if necessary. The leaders also provide a process for physicians and health care professionals to explain variations from the clinical practice guidelines. The clinical guidelines are periodically reviewed and modified as necessary.