On the CUSP: STOP BSI Identifying Barriers to Evidence-based Guideline Compliance

1. On the CUSP: STOP BSI Identifying Barriers to Evidence-basedGuideline Compliance

2. Learning Objectives • To identify different types of barriers to guideline compliance • To apply knowledge to identify real barriers to guideline compliance in participating units • To describe a process to eliminate or reduce the effects of these barriers • To discuss barriers and solutions in a cross-team group setting

3. Evidence-based Behaviors to Prevent CLABSI • Remove unnecessary lines • Wash hands prior to procedure • Use maximal barrier precautions • Clean skin with chlorhexidine • Avoid femoral lines

4. Ask Front-line Staff • What are some of the leading problemsand barriers encountered in your unit that may hinder compliance with this guideline? • Does the front-line staff know what is expected from them regarding guideline compliance? Do they agree with the guideline? • Whatare some of the strategies and tools you have implemented toimprove compliance with this guideline in your unit?

5. Specific Items • Who are the care providersresponsible for ensuring compliance with this guideline? Canyou describe their roles with regards to complying with thisguideline? • What information do you need to be able to followthis guideline? • How do you findout the date that a central venous catheter was inserted to a patient? • What are yourpractices to reduce central venous catheter-related bloodstreaminfections? What are the common lapses in compliance?

6. Observe • Shadow a care provider while following a guideline (multiple times, multiple providers) • Include different lenses – nurse, infection control, human factors/ QI expert shadowing physician • Focus on system characteristics rather than the individual physician

7. Try out the Guideline • Triability of a guideline increases guideline compliance • Usability testing of a technology (guideline) • Walkthrough: Walk the process of inserting and maintaining a central line • Scenario-based testing • How easy is it to comply with the guideline?

8. Types of Barriers (4As) • Awareness → Implement education • Agreement → Group discussion • Ambiguity → Clarify any type of ambiguity • Ability → Identify any impeding system factors and eliminate them or reduce their impact

9. Beliefs of a Clinician • Behavioral beliefs: Does complying with a guideline lead to positive outcome(s)? • Normative beliefs: What are the expectations of my colleagues regarding complying with a particular guideline? • Control beliefs: What are the factors that may impede or facilitate guideline compliance and how much I can control these?

10. Ambiguities • Task ambiguity • Expectation ambiguity • Responsibility ambiguity • Method ambiguity • Exception ambiguity

11. Examples of Barriers • Unclear feedback (expectation ambiguity):Presenting bloodstream infectionrates in the format of 4.6 per 1000 line days is not perceivedby nurses as directly relevant to their practice • Forgetting to review line necessity daily due to inadequate reminder mechanism • High workload negatively affecting hand washing compliance • Central line cart is not stocked regularly

12. Identifying Barriers • Conduct preliminary interviews to understand causes of non-compliance. Is guideline compliance intentional or non-intentional? • Non-intentional: Interview care provider • Intentional: Conduct observations and interviews • Include different types of care providers in the process of identifying barriers (physicians, nurses, respiratory therapists, infection control, human factors expert)

13. Reporting Findings Reporting framework • Provider: job category, skills, beliefs • Tasks: Ambiguities (role, task, exception), guideline • Environment • Tools • Organization Interdisciplinary meeting • Discuss findings • Prioritize barriers and develop action plans

14. Action Plan • Form an interdisciplinary group of people (physician, nurse, inf control, resp therapy, human factors/QI expert, other) responsible for identifying barriers. • Each one conducts at least one observation and one interview. • People from two different disciplines walk through the process together. • Summarize findings using the barrier reporting framework. • Discuss findings in an interdisciplinary meeting (including unit administrators) and prioritize the barriers to tackle. • Identify action plans and assign responsibilities. • Review the progress periodically.

15. References • Azjen (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50, 179-211. • Carayon et al. (2006) Works system design for patient safety: the SEIPS model. QSHC 15: i50 - i58. • Gurses et al. (2008) Systems ambiguity and guideline compliance, QSHC 17:351-359 • Pronovost et al. (2008). Translating evidence into practice: a model for large scale knowledge translation. BMJ 337:a1714 • Reason (1990) Human Error. Cambridge University Press, Cambridge. • Rogers, E. M. (1995). Lessons for guidelines from the diffusion of innovations. Jt.Comm J.Qual.Improv. 21, 324-328. • Thompson (2008) View the world through a different lens: shadowing another Jt.Comm J.Qual.Improv . 34, 614-618(5).

16. Interactive Activity • Pair older teams with new teams • Pick one of 3 discussion topics • Group discussion (~30 minutes) • Groups report out on barriers and solutions (~10 minutes)

17. Discussion Groups • Not enough engagement • Not enough time • Not enough communication

18. Not Enough Engagement • With regards to: • Senior executives • Physicians • Nurses • Quality officers • Infection preventionists • Others What barriers has your team faced engaging this group? How have/could you respond? What worked or didn’t? Why?

19. Not Enough Time • How do you overcome barriers to senior leadership availability? • How do you overcome barriers to unit-level availability to do the work? • How do you manage data within the time constraints of your work?

20. Not Enough Communication • How do you create a communication “vessel”? • How do you communicate the goal and the process for getting there? • How do you empower staff to speak up? • How do you set clear expectations avoiding role and task ambiguity? • How do you foster using clear and concise language?