Abstract
BackgroundIn mental health settings, implementation of and adherence to clinical practice guidelines (CPGs) is low. Strategies are needed to overcome barriers and facilitate successful implementation of CPGs into standard care. The goals of this study were to develop a framework for the implementation of a CPG for schizophrenia for hospitalized service users in a mental health care facility, and to monitor adherence to the guideline.MethodsAn eight-step framework was developed based on project management principles: 1) the Appraisal Guideline for Research and Evaluation (AGREE) tool was used to rate and select a CPG; 2) an algorithm was created from the guideline; 3) a gap analysis identified clinical services and processes not conforming with the CPG recommendations; 4) a governance structure was created; 5) a modified Delphi process determined key outcome and process adherence metrics; 6) a project charter was developed; 7) clinical informatics ensured that systems and tools were in place to support the CPG; and 8) therapeutic services were realigned to match the requirements of the CPG within specified fiscal constraints. Percent adherence to the identified process adherence metrics was calculated before (March 2014) and for 12 months after implementation (April 2014-March 2015).ResultsThe National Institute of Health and Care Excellence guideline scored highest on AGREE and was used to develop the algorithm. Cognitive behavior therapy for psychosis (CBT-P), art therapy and carer assessments were identified as gaps in care. Clinical global impression – Schizophrenia score was identified as the primary service user outcome variable and antipsychotic polypharmacy, metabolic monitoring, CBT-P referral and supported employment/vocational services referral as the primary process adherence measures. Adherence to guidance for metabolic monitoring (March 2014, 76.7 %; March 2015, 81.6 %), CBT-P referral (March 2014, 6.5 %; March 2015, 11.4 %) and vocational rehabilitation referral (March 2014, 36.6 %; March 2015, 49.1 %) were increased after CPG implementation. There was an initial increase in adherence to antipsychotic monotherapy (March 2014, 53.4 %; November 2014, 62.7 %), which decreased back toward baseline (March 2015, 55.1 %).ConclusionsThe eight-step framework was used to implement a CPG process, though further quality improvements initiatives may be needed to improve adherence.
Highlights
In mental health settings, implementation of and adherence to clinical practice guidelines (CPGs) is low
the appraisal guideline for research and evaluation (AGREE) analysis Based on the CPG review completed by Gaebel et al [16] and the review of the Canadian Psychiatric Association guidelines completed by Ontario Ontario Shores Centre for Mental Health Sciences (Shores)’ clinicians, the National Institute for Health and Care Excellence (NICE) CPG for assessment and treatment of schizophrenia [21] was selected, as it was the highest ranked CPG according to the AGREE analysis with a total score of 90 [16]
Four process adherence measures were identified, with percentage of service users on multiple antipsychotics ranked as number one, followed by percentage of service users with all five metabolic risk factors monitored at recommended intervals, percentage of service users who had been referred for supported employment/vocational services, and percentage of service users who had been referred to Cognitive behavior therapy for psychosis (CBT-P)
Summary
Implementation of and adherence to clinical practice guidelines (CPGs) is low. Strategies are needed to overcome barriers and facilitate successful implementation of CPGs into standard care. The goals of this study were to develop a framework for the implementation of a CPG for schizophrenia for hospitalized service users in a mental health care facility, and to monitor adherence to the guideline. Results from physician surveys have identified a number of barriers to the adoption of, and adherence to, CPGs including: lack of awareness of or disagreement with guidelines; insufficient motivation to change; negative attitudes toward guidelines in general; faith in existing treatment practices; and lack of time, availability and organizational support [11, 12]. The local context has been identified as an important factor in determining the success of CPG implementation [11]. A recent review determined that multifaceted implementation strategies including educational materials or meetings along with reminders and coordination by a member of the healthcare team were most likely to improve adherence following CPG implementation [13]
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