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 Healthcare System.
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: