P2.272: Establishing Governance for a Clinical Care Guideline Program

Purpose/Objectives: Clinical Care Guidelines (CCGs) encourage evidence-based practice and decrease variation in care. At our institution, no formal oversight for CCGs existed. We established a governance structure to create and manage processes that ensure periodic evidence integration and monitoring of quality metrics. Our goal was to identify ownership and initiate updates for 80% of guidelines that had not been revised for 5 years. These new processes ensure accountability and support achievement of top-tier clinical outcomes.

Design/Methods: We formed a Steering Committee to manage governance processes. This group established approval criteria for new and revised CCGs, specifying that literature reviews must be updated at least every 5 years. We created a system for cataloging CCGs, including clinical owners and date of next review. At baseline, 26 CCGs required review and 31% of those CCGs had clinical owners listed. We identified owners, initiated updates, and established a process for Steering Committee review of CCGs before implementation. Quality data are presented after CCG implementation at a new governance meeting to ensure awareness and accountability. The governance structure was co-designed by two physicians, one nurse, one nurse informaticist and an improvement consultant, all experienced in Lean Six Sigma methodology. The governance committee has more than 40 interdisciplinary members who convene bimonthly to discuss CCG data and spread knowledge of CCGs to their respective teams.

Results: Updates were initiated for 85% of the 26 CCGs that had or would pass the 5-year threshold within the fiscal year; 9% of updates were completed, 55% are in process, and 36% were retired or redefined as something other than a CCG. Ownership documentation increased from 31% to 88%. Improvements were dependent on manual processes and required a dedicated staff member that allocated 25-50% of their time to the effort monthly.

Conclusion/Discussion: Organization and standardized processes are key elements of CCG program governance and allow for more consistent engagement of stakeholders. Creation of this infrastructure is time-consuming but essential to ongoing success. Sustainability will depend on continued dedicated staff time for oversight activities. Having established baseline operations, our next goal is to develop sustainable measurement systems that minimize manual data analysis for CCG owners. We will make iterative improvements to the format of the governance committee meetings based on feedback and quantify impact of the program by tracking outcomes and monthly patient populations.