Integration of performance measures into CPGs

Dr.Patrice Lindsay, Director, Performance and Standards, Canadian Stroke Network, and Appointed Member, Canadian Task Force on Preventive Health Care

Accountability in healthcare has become the modern mantra for healthcare organizations at all levels -- from local hospitals, regional health authorities and provincial ministries of health. The intention is to ensure that Canadians are getting equal access to healthcare services in a timely manner and in the right setting with the appropriate expertise to meet the needs of the patient. As straight-forward as this sounds, the challenges in meeting accountability demands are numerous and complex. 

In a significant step forward in Canada, the provincial Health Ministers now are emphasizing the value and role of CPGs in increasing consistency and defining what healthcare organizations will be accountable for delivering. The Canadian Best Practice Recommendations for Stroke Care are a strong example of the potential impact of guidelines on accountability at a program, regional and provincial level. The recommendations are featured in video 3 of the Health Council’s video series on CPGs.

The Canadian Best Practice Recommendations for Stroke Care were developed through a partnership of the Canadian Stroke Network and the Heart and Stroke Foundation. Prior to guideline development in 2006, clinicians across Canada referred to guidelines from other countries, and there was a lack of standardization, even within the same city or organization. Now, they have become the 'go to' resource for all stroke programs in Canada, and for many stroke providers internationally. This widespread uptake of these guidelines has led to significant and measurable systems change and improvements in stroke care and patient outcomes.

A key innovation in the stroke guideline development was including a set of validated performance measures and linking them directly to the evidence-based practice recommendations. At the time of guideline release, there did not appear to be any other published CPGs that had included performance indicators so directly. The stroke CPGs inform healthcare providers on what they should be doing, and the performance measures inform the providers on how well they are delivering that care. These indicators are clearly defined in our Stroke Performance Measurement Manual (www.strokebestpractices.ca). These key performance indicators formed the foundation of our national stroke audit for the 2008-09 fiscal year. When the audit results were released, decision-makers and system leaders were able to track back to the guidelines and identify services where performance was good, as well as identify areas where quality improvement initiatives were required. Since the release of the Quality of Stroke Care in Canada 2011 report, several new stroke units have been developed, door-to-needle times for clot-busting drugs have been reduced, and more patients are getting access to stroke prevention therapies. Further, the data has led to the establishment of national and regional benchmarks for stroke care delivery in Canada. Providers now have a mechanism to compare their care delivery with validated benchmarks and targets.

Integration of performance measures into any CPG is valuable and does not require significant resources. The decision to do this should be made prior to conducting evidence searches so that key questions regarding performance indicators can be searched simultaneously.

Developing and disseminating guidelines is no longer enough. It is really only a part of the responsibility of guideline groups, especially when the guidelines define the nature of accountability for care. The whole package includes performance measures to identify how well care is delivered; educational materials to support the clinicians in learning 'how' to deliver the care described in guidelines; and instruction on how to measure that care. Finally, the package needs to include effective dissemination strategies that go beyond publishing the guideline document.