The JCAHO standards do not mandate implementation of guidelines, however guideline recommendations should be considered when physicians and other caregivers are designing or improving processes. The standards state, "new or modified processes are designed well," meaning that the organization should use a variety of information sources including practice guidelines, literature resources, and information from other outside sources. This information is to be used during step one of a process improvement project.

Process improvement involves three steps: (1) Define the ideal process; (2) Implement the ideal process; (3) Measure the impact of process redesign. During step one, information gathered from various sources is used to define the ideal or "best" process. Before the medical profession accelerated systematic development of clinical practice guidelines in the 1990's, caregivers at the local level were the ones who defined appropriate patient care practices. The definition of best practice was derived from the organization’s traditional way of doing things and the subjective opinions of practitioners. According to Joint Commission standards, these local opinions should now be supplemented by scientific and literature evidence of what works best.

The accreditation standards do not require that caregivers blindly adopt all guidelines. However, there should be evidence that practitioners reviewed and considered relevant guidelines and literature sources when designing or re-designing patient care processes.

Clinical practice guidelines should also be considered when developing measures of clinical performance. These measures should be based in part on the evidence-based recommendations found in clinical practice guidelines. For example, the American Society for Gastrointestinal Endoscopy has developed guidelines that address the management of anticoagulation and antiplatelet therapy for patients undergoing endoscopic procedures. The guidelines recommend that warfarin therapy for patients with high-risk conditions be discontinued three to five days before a scheduled endoscopy procedure. High-risk conditions may include atrial fibrillation associated with valvular heart disease, including the presence of a mechanical valve, mechanical valves in the mitral position, and mechanical valves in patients who have suffered a prior thromboembolic event. If the surgery department is evaluating the quality of care provided to patients undergoing endoscopic procedures, one of the measures might be, "Percent of patients on warfarin therapy for a high-risk condition who discontinue therapy at least three days prior to the endoscopy procedure." This would be considered a guideline-based measurement.

Guidelines can also be valuable sources of comparative data if the guidelines are explicit and there is good scientific evidence to support the recommendations. For example, there is very good evidence to suggest that prophylactic antibiotics be administered in the two hours before surgery to reduce the risk of wound infection. Anything less than 100 percent compliance with this guideline should prompt further investigation.

The days of "starting from scratch" when defining the best clinical processes for achieving desired patient outcomes are nearing an end. When undertaking a clinical process improvement project or when evaluating performance, the Joint Commission expects practitioners to consider the recommendations found in knowledge-based sources. These recommendations may come from professional medical societies and physician organizations, nursing and allied healthcare associations and policy-making bodies, and/or local organizations. Knowledge-based information helps to broaden the perspective of physicians and other caregivers, who have traditionally relied on personal experiences to define best practices.

Copyright 2002 by Brown-Spath & Associates

To Learn More: Patrice L. Spath is available for in-house presentations on this and other healthcare performance improvement topics. For further details, visit Brown-Spath & Associates on the web at: http://www.brownspath.com or write to: Brown-Spath & Associates, PO Box 721, Forest Grove, OR 97116.

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