Partners in Performance & Quality Care

The Hospitalist. 2006 March;2006(03):

March 1, 2006 | The Hospitalist

In fact, says Dr. Simone, hospitalists who have experience and knowledge about guideline development and implementation will be considered tremendous assets by hospitals. “If the nationwide use of guidelines in hospitals isn’t common yet, it will be in the coming years. And hospitalists are perfectly positioned to take the lead on the effective development and use of these tools,” he offers.

Tips for Effective Order Set Development and Implementation

It is always challenging to initiate any type of widespread change, and the implementation of order sets is no exception. However, there are several tips that can help gain stakeholders’ buy-in and ensure that the tools are used consistently and properly:

Involve hospitalists in the development of guidelines and give them the opportunity to review and approve all order sets to be used in their facility;
Avoid establishing or promoting a system in which hospitalists or other physicians customize or use their own guidelines. It is important not to have practitioners using several order sets or even multiple variations of a single set at one facility;
Consider the practicality of all steps involved, not only for physicians, but also for nurses, pharmacists, and other team players. If even one step is thought to be unrealistic or impractical, it could hurt the credibility—and use—of the entire document;
Educate physicians and others about why the guideline is important and the goal of its use. While cost-effectiveness may be a legitimate reason to implement such tools, de-emphasize this purpose to physicians. Instead, stress quality patient care because this is a goal they understand and share. When it is important to emphasize financial considerations, “stress savings to the patient and the U.S. healthcare system, and not organizational cost-savings or increased profits,” says Dr. Simone; and
Avoid implementing guidelines and assuming they are being used. Monitor use over time and tweak the sets as necessary.

While following such steps doesn’t guarantee successful guideline development or implementation, it can help minimize barriers and increase practitioners’ belief in the value of the guideline. If physicians and others believe that a tool will improve patient care and make the best use of their time, they are more likely to embrace than reject them.—JK

Tools that Teach

Guidelines encourage standardization of care and help physicians and other clinicians quickly select appropriate assessments and interventions for various conditions. They also help prescribers make appropriate medication and dosage selections quickly and accurately. For example, an order set for admissions to a coronary care unit (CCU) for acute coronary syndrome likely will address considerations such as nursing orders, IVs, medications, diagnostic tests, consults, discharge planning, and primary care follow-up.

Used properly, these tools do not promote “cookbook” or “cookie cutter” medicine—as some opponents suggest; instead, they guide decision-making and enable practical, evidence-based choices for each patient.

Hospitals and hospitalists most frequently employ guidelines regarding the clinical conditions that most commonly lead to ED visits or hospital stays. These include community-acquired pneumonia, COPD, CHF, chest pain, MI, and stroke.

In choosing topics on which to implement guidelines, Dr. Simone suggests considering the demographics, needs, and challenges of the particular facility. For example, “if you have guidelines addressing diagnoses for which patients generally are put on 24-hour observation prior to hospital admission, you can ferret out who needs to be admitted and who doesn’t,” he says, adding, “and you can make these decisions in a consistent manner.”

Buy-in and Barriers

Hospitalists who use guidelines agree that they are natural leaders when it comes to the development, implementation, and use of these tools.