(Management Case Study) Integration of System-Wide Clinical Practice Guidelines Using Frontline Clinical Pharmacists

Purpose: Through acquisition of additional hospitals to a rapidly growing health system, clinical practice guidelines and other clinical resources varied between institutions. This case describes the methods by which a newly formed enterprise-wide medication use team utilized front-line clinical pharmacists to address the need for standardization of clinical resources and practice guidelines using evidence-based medicine and best practices and improve document control for a twenty-hospital health-system.  This case aligns with the Practice Advancement Initiative domain encompassing leadership in medication use and safety, as well as integrating pharmacy enterprise for convenient and cost-effective care.

Methods: The focus of this project was to provide more easily retrievable clinical practice guidelines, improve system collaboration and practice standardization, and increase overall productivity. Staff engagement surveys indicated a level of frustration with the lack of standardization for clinical resource documents and unintuitive organization of the document storage. The health-system Medication Use division was assigned responsibility for the oversight of all clinical practice documents applicable to the health-system. In partnership with pharmacy leadership at the flagship academic medical center, a plan to catalogue current resources and utilize front-line clinical pharmacists and physicians to review documents for relevance and agreeance with current practices. All existing documents were organized for staff to review with manager oversight. After review, teams established ownership of documents and planned for updates based on original author/division.

Standardized templates were developed to ensure all documents included authors, committee approval, date approved and subsequent revisions.  These templates were developed for clinical practice guidelines, clinical pathways, best practice summaries, quick reference guides and SBARs for communication purposes. Pharmacist project days were utilized to update all clinical resources using evidence-based literature and best practice statements. Subcommittees of the health-system Pharmacy and Therapeutics Committee vetted the documents and voted on approval prior to enterprise-wide adoption. Documents were then uploaded to an enterprise intranet webpage with an archived, editable version on cloud-base shared drive for future updates.

Results: There were 209 clinical practice resource documents catalogued initially for review. Barriers to the project included locating existing resource documents, such as those cross-posted in multiple locations and coordinating the update of links with the electronic medical record. Identifying the original author and/or approving hospital committee, as well as the party responsible for future updates was another barrier to overcome. Of the original 209 resource documents catalogued, 42 documents were identified as needing revisions to align with current practice and 37 documents were recommended for deletion. In the past six months since the project started, 39 guidelines or clinical pathways have been drafted and approved for system-wide use and posted electronically. A total of 144 pharmacist project days have been allocated so far to review and standardize these documents, in addition to other medication use projects such as formulary management, medication use evaluations (MUEs), electronic health record optimization and continuing education materials. Clinical pharmacist-led document reviews have ensured resources remain relevant and useful to frontline staff. Overall staff feedback on the new standardization of document styles, naming conventions, and online storage location has been overwhelmingly positive as the number of documents converted continues to increase.

Conclusion: As new hospitals join a pre-existing health-system, often there are significant variations in clinical practice which can lead to inconsistent approaches to care. The model described in this project allows for the integration of frontline staff to serve as content-matter experts while prioritizing standardizing best practices across the system. This has proven to be a successful strategy due to pharmacists’ strong relationships with other disciplines, application of direct patient care experiences, and the ability to tailor work to a variety of frontline pharmacists with vast clinical backgrounds to address staff engagement, increase patient safety, and improve patient outcomes.