Guidelines will not solve every problem, as Dr Mark Charny explains in the second article in this series
Guidelines are not the answer to every problem. You need to define what you are trying to achieve, and then choose a suitable tool for the job. There are two key questions to consider:
- Do you have a problem?
- If you do, will a guideline help?
It is easy to overlook problems that we do have – our blind spots. We assume that the way we do things is for the best, or that circumstances prevent things from being better.
But it is also easy to think you have a problem when you haven't, especially when you compare the way things are with the way you would like them to be in an ideal world.
Problems are identified in an absolute or a relative (comparative) way. Maternal deaths are generally considered unacceptable and, by definition, are a problem even if subsequent investigation suggests that the woman received the best possible care. Similarly, prescribing the wrong drug or the wrong dose of a drug may be considered unacceptable, as might failure to obtain informed consent. In these examples, we are interested in every instance of the event, whether or not others have a higher or lower rate of events.
Most problems, however, are defined in a relative way. For example, when we consider wound infection following surgery, patient satisfaction, hip replacement failure rate, or screening rates, we may choose to define a problem by comparison with figures achieved by others in similar circumstances. A 90% screening rate may not be considered a problem if similar practices achieve 85%, but may give rise to concern if similar practices achieve 95%.
Sources of comparative data include:
- Routine statistics, such as PACT and Hospital Episode Statistics
- Repeated surveys, such as the General Practice Morbidity Survey
- Ad hoc enquiries, such as local lifestyle surveys and many audits
- Comparison of your practice with estimates or descriptions in the published literature
- Anecdotal evidence, such as conversations between partners in a practice, between practices in a PCG, and discussions at PGMC events etc.
Having satisfied yourself that you have a problem, you need to consider whether a guideline is going to improve matters. As discussed in the previous article in this series, guidelines cover all sorts of activity and come in various forms. The need for a guideline can only be established in respect to a specific document in a specific context.
- A practice finds that too many patients receive repeat prescriptions without seeing a doctor after an agreed period. The practice may agree that no-one should receive repeat NSAID prescriptions for more than a year without being seen in the surgery. A guideline may be drawn up and issued, but it may be much simpler to alter the computer system so that a repeat prescription cannot be printed out for a period of longer than one year without new authorisation from the prescriber.
- Local screening rates may be lower than average. Instead of introducing a guideline, an ad hoc survey may reveal that those who do not accept screening invitations tend to have child-care problems, and providing creche facilities or offering appointments in the evenings or on Saturday mornings may increase rates.
- A practice may not be as successful as comparable practices in opportunistic screening for cardiovascular risk factors in middle-aged patients. A guideline may be very valuable in reminding everyone about which patients should be screened opportunistically, and which measurements or tests or questions are appropriate. The receptionist might flag the notes of apparently eligible patients, the practice nurse may make agreed measures, and the nurse or doctor may take action in accordance with the guidelines in the light of the results.
Don't assume that you have a problem – check it out and choose an approach that offers the most gain with the least pain.
Guidelines are often complex and will not usually work without a good deal of implementation effort. In general, structural solutions agreed by the practice (e.g. automatically highlighting abnormal test results) generate more lasting results with less effort.
Conveying detailed information and persuading people to read it, absorb it and act on it is often necessary in clinical work, but don't embark on an educational and developmental approach unless you have considered the alternatives carefully.