Guideline Implementation in Standardized Office Workflows and Exam Types

Background: Clinical practice guidelines (CPGs) in medicine are recommendations supported by systematic review of evidence to facilitate optimal patient outcomes. Primary care practices are expected to implement more than 200 CPGs, overwhelming many practices. This qualitative study elucidated the perspectives and priorities of family medicine physicians and office managers in grouping CPGs to facilitate implementation. Methods: A qualitative study was performed using individual, semistructured interviews. During the interviews the participants completed an open card-sort exercise grouping 20 CPGs. Purposive sampling was used to identify family medicine physicians and office managers practicing in medically underserved zip codes listed in the local medical society directory. Seven physicians and 6 office managers were interviewed. The interviews were transcribed and analyzed using thematic analysis and compared with the card-sort results. Results: Thematic content analysis identified priorities and perspectives of office managers and physicians when grouping multiple CPGs for implementation: delegation, personalization, triggers, and change management. The card sort exercise revealed grouping by standardized preventive care visit, standardized rooming and discharge processes, and chronic illness. Chronic illness-based groupings and personalization of guidelines were recognized as presenting barriers to delegation of CPGs to the care team. Development of standardized preventive exams, standard rooming and discharge processes and chronic disease management were identified as promoting CPG adherence through team-based care. Standardized workflows provided opportunities for task delegation through predicable roles. Medicalization of CPG implementation relied heavily on the physician alone to remember to adhere to CPGs and inhibited task sharing by not giving office staff clear disease-based protocols to follow. Conclusions: This study identified priorities and perspectives of office managers and physicians when grouping multiple CPGs for concomitant implementation: delegation, personalization, triggers, and change management. Successful implementation was perceived to be associated with standardized preventive exams, standard rooming and discharge processes, and chronic disease management.