Identifying Barriers to Evidence-based Guideline Compliance

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

2. Learning Objectives • To learn about the different types of barriers to guideline compliance • To learn how to identify the barriers to guideline compliance • To understand how to develop strategies to eliminate or reduce the effects of these barriers

3. Compliance with Evidence-Based Guidelines • Consistent compliance with evidence-based guidelines is challenging yet critical to patient safety. • Need for interdisciplinary approach to improve compliance • From human factors point of view: Compliance as “systems property.” • GOAL: To identify and eliminate/mitigate the effects of barriers to compliance with guidelines

4. 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

5. Steps of Barrier Identification and Mitigation Tool (BIM)* • Step 1: Assemble the interdisciplinary team • Step 2: Identify barriers • Observe the process • Walk the process • Ask about the process • Step 3: Summarize barriers in a table • Step 4: Prioritize barriers • Step 5: Develop an action plan for each prioritized barrier * Gurses et al. (2009) A practical tool to identify and eliminate barriers to evidence-based guideline compliance. Joint Commission Journal on Quality and Patient Safety 35(10):526-532 .

6. Step 1: Assemble the Team • Nursing • Infection Prevention • Managers • Senior Executives • Human factors/QI

7. Step 2: Identify Barriers • Observe the Process • Include different lenses – nurse, infection prevention, human factors/QI expert, managers, etc., to participate in observations • Why is it difficult to comply? • Steps skipped, work-arounds

8. Step 2: Identify Barriers • Ask about the process: Ask staff • Whether they are aware of/agree with the guideline • What are some of the leading problemsand barriers encountered in their unit that may hinder compliance with this guideline? • If they have any suggestions to improve compliance with the guideline • Specific questions (e.g., How do you findout the date that a central venous catheter was inserted to a patient?) • Walk the process • Try to comply with the guideline using simulation or, if appropriate, under real circumstances.

9. Types of Barriers • Provider • Knowledge, attitude • Current practice habits • Guideline-related • Applicability to patient population • Evidence supporting guideline • Ease of compliance • System • Supplies/equipment unavailable • Inadequate or poorly designed tools and technologies • Poor organizational structure (e.g., staffing, policies) • Inadequate leadership support • Unit/hospital culture • Inadequate feedback mechanisms • System ambiguities • Other

10. Systems Ambiguity* as a Barrier to Guideline Compliance • Ambiguity Types • Task • Responsibility • Expectation • Method • Exception * Gurses AP, et al.Systems ambiguity and guideline compliance: A qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Quality and Safety in Health Care, 2008; 17(5):351-59.

11. Method Ambiguity • Complexity of some of the guidelines and the demanding work environment of ICUs “The tight glucose protocol is very wordy and I don’t have enough time to go and look through it…I’ve developed my own way of calculating the insulin that needs to be given. I’ve done this job quite enough that I can guess how much insulin to give based on trends [in patient’s condition]…I feel like it’s [following the TGC] going to take more time to achieve the goal than I’ve been able to achieve already [using my own method].” • Being able to quickly find the necessary supplies without spending time searching was reported as a key factor in complying with some guidelines “It is really easy to comply with the central venous catheter (CVC) insertion guidelines in this unit because everything you need is available on the [CVC insertion] cart.”

12. Barrier Identification Form

13. Step 4: Barrier Summary and Prioritization • *Likelihood score: How likely will a clinician experience this barrier? • Remote 2. Occasional 3. Probable 4. Frequent • †Severity score: How likely will experiencing a particular barrier lead to non-compliance with guideline? • Remote 2. Occasional 3. Probable 4. Frequent • ‡Barrier priority score = Likelihood score X Severity score

14. Step 5: Development of Action Plan *Potential impact score: What is the potential impact of the intervention on improving guideline compliance? 0. No impact 1. Low 2. Moderate 3. High 4. Very high †Feasibility score: How feasible is it to take the suggested action? 0. Not feasible 1. Low 2. Moderate 3. High 4. Very high ‡Action priority core = Potential impact score X Feasibility score

15. References • Carayon et al. (2006) Works system design for patient safety: the SEIPS model. Quality and Safety in Health Care 15: i50 - i58. • Gurses et al. (2009) A practical tool to identify and eliminate barriers to evidence-based guideline compliance. Joint Commission Journal on Quality and Patient Safety 35(10):526-532 • Gurses et al. (2008) Systems ambiguity and guideline compliance, Quality and Safety in Health Care 17:351-359 • Gurses et al. (2010) Using an interdisciplinary approach to identify factors that affect clinicians’ compliance with evidence-based guidelines. Critical Care Medicine Forthcoming. • Pronovost et al. (2008). Translating evidence into practice: a model for large scale knowledge translation. British Medical Journal 337:a1714 • Thompson et al. (2008) View the world through a different lens: shadowing another Joint Commission Journal on Quality and Patient Safety 34, 614-618(5).