Eight steps to creating 'living' clinical guidelines

Guidelines evolve based on patient data

Topics: Pediatrics, Service Lines, Access to Care, Quality, Performance Improvement, Appropriateness, Safety, Service, Readmissions

May 7, 2013

Physicians at Boston Children's Hospital and Harvard Medical School say they have developed "living" guidelines that "narro[w] practice variability while still permitting providers to exercise their clinical acumen."

Writing in Health Affairs this month, the physicians—as well as a senior vice president at Blue Cross and Blue Shield of Massachusetts—acknowledge the limitations of most clinical practice guidelines. "In short, clinical practice guidelines are limited in their ability to deliver what our health care system needs: a way to promote greater care standardization that accommodates patients' differences, respects providers' clinical acumen, and keeps pace with the rapid growth of medical knowledge," they write.

The Standardized Clinical Assessment and Management Plans (SCAMPs)—developed voluntarily by physicians and nurses—"represent a promising alternative to, and improvement on, clinical practice guidelines," they write.

SCAMPs aim to reduce practice variation, optimize resource use, and improve care. To develop a SCAMP for a condition, a clinician group must follow eight steps:

  • Create a background position paper on a particular condition that examines medical literature and existing guidelines;
  • Determine which patients to include, which clinical assessments to use, and how to structure treatment for the condition;
  • Identify knowledge gaps and data to be collected;
  • Develop data forms and electronic tools to collected necessary data;
  • Pilot the SCAMP;
  • Gather data from clinicians;
  • Analyze data from SCAMP after a set time period; and
  • Use the data analysis to modify the SCAMP.

According to the Health Affairs article, it typically takes three to six months before a SCAMP is ready for implementation. Each round of data analysis and SCAMP modification then takes another one to two years.

To date, Boston Children's has developed SCAMPs for 49 medical conditions. "We're creating living guidelines in a way that we can gather information and learn from every encounter," says Michael Farias, a pediatric resident and one of the SCAMPS developers. "It's not all about reducing resource use, it's about optimizing it."

Through the program, the hospital found that doing cardiac imaging on every 12-year-old child who had a particular type of surgery was unnecessary. The program also:

  • Decreased the cost of caring for children with six different kinds of cardiovascular problems by 27%;
  • Increased the rate of "ideal" outcomes for children with a congenital condition from 40% to 69% over a one-year period; and
  • Increased the rate of physicians who complied with recommended specialist referrals from 20% to 75%.

About 20 hospitals—including non-pediatric facilities—now use SCAMPS, according to KHN (Farias et al., Health Affairs, May 2013; Appleby, "Capsules," Kaiser Health News, 5/6).

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