FORT LAUDERDALE, Fla--The most difficult part of the guidelines
process is implementation--getting physicians, nurses, and administrators
to "buy in" to the process, Gale Katterhagen, MD, said
at the first annual conference of the National Comprehensive Cancer
Network (NCCN), a coalition of major cancer centers currently
in the process of developing guidelines for its members.
The real moment of truth for any guideline or clinical path, Dr.
Katterhagen said, is the documentation that outcomes and costs
have been impacted.
"Has the guideline produced value for the institution? Unless
clinical guidelines affect physicians' prescriptive practices,
and drive practice variation and inappropriate care out of the
system," he said, "they will not have a significant
impact on costs and outcomes."
The market is driving the process, with purchasers demanding accountability
in costs and outcomes. When purchasers talk about quality, he
said, they are really talking about outcomes--patient satisfaction;
clinical outcomes, both morbidity and mortality; and quality of
life (which is now often referred to as "functionality").
Purchasers want good value, as defined by the equation: outcomes
divided by costs.
Dr. Katterhagen has direct experience with the guidelines process
in his role as chairman of the Clinical Quality Council for the
San Francisco-based, 23-hospital, not-for-profit Sutter-California
He said that at Mills-Peninsula Hospitals, Burlingame, where he
is medical director of the Cancer System and Breast Center, physicians
are deeply involved from the outset in the development of clinical
paths. The development groups "work backwards," he said,
first defining outcomes, then selecting the process, or order
set, to be followed for the specific DRG or condition.
Over the course of 3 years of involvement in the guidelines process,
Dr. Katterhagen said that he has learned to anticipate many of
the obstacles to implementation: