Evaluation of the Low Back Pain Practice Guideline Implementation in the Army Medical Department

RAND is assisting the Army Medical Department to develop and test methods to effectively implement clinical practice guidelines in the Army treatment facilities to achieve consistent and quality clinical care practices across the Army health system. This report presents the final results of the evaluation that RAND conducted as part of the demonstration for the low back pain practice guideline, which was conducted in 1999 and 2000. The evaluation includes (1) a process evaluation of the experiences of the participating military/medical treatment facilities (MTFs) and (2) a quantitative evaluation to assess effects on processes of care associated with the introduction of best practices recommended by the practice guideline. In the evaluation, the authors assess the performance of demonstration participants on these factors: (1) visible and consistent commitment by the U.S. Army Medical Command (MEDCOM) leadership at all levels, (2) ongoing monitoring and reporting of implementation progress in carrying out an action plan, (3) implementation guidance to the MTFs by MEDCOM, (4) identification of an effective physician guideline champion at each MTF, (5) dedicated time and adequate resources for the guideline champions, and (6) rapid integration of new practices into a clinic's normal procedures. Guided by the experiences of the low back pain demonstration, as well as the subsequent asthma and diabetes guideline demonstrations, a corporate implementation strategy emerged that was found to be an effective and efficient approach for practice guideline implementation in the Army Medical Department. Continuous quality improvement techniques served well in planning and carrying out the implementation steps: (1) preparation of a realistic action plan by each MTF that defines a focused strategy and sets of actions to introduce the guideline and to change clinic procedures (where needed), (2) performance of the defined actions by designated staff, (3) ongoing monitoring of progress in making intended practice changes through the actions undertaken, and (4) adjustment of action strategies in response to monitoring findings. This process is based on the recognition that quality improvement involves a series of manageable, incremental steps, each of which builds on previous steps over time to achieve continual improvements in health care processes and outcomes.