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

Guideline ComplianceGuideline Compliance

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Learning ObjectivesLearning 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 a process to eliminate or reduce the effects of these barriers

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• Remove unnecessary lines

• Wash hands prior to procedure

• Use maximal barrier precautions

• Clean skin with chlorhexidine

• Avoid femoral lines

Evidence-based Behaviors to Evidence-based Behaviors to Prevent CLABSIPrevent CLABSI

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Ask Front-line StaffAsk Front-line Staff

• What are some of the leading problems and 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?

• What are some of the strategies and tools you have implemented to improve compliance with this guideline in your unit?

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Specific ItemsSpecific Items

• Who are the care providers responsible for ensuring compliance with this guideline? Can you describe their roles with regards to complying with this guideline?

• What information do you need to be able to follow this guideline?

• How do you find out the date that a central venous catheter was inserted to a patient?

• What are your practices to reduce central venous catheter-related bloodstream infections? What are the common lapses in compliance?

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ObserveObserve

• 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

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Try out the Guideline Try out the Guideline

• Triability of a guideline increase 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?

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Types of Barriers (4As)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

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Beliefs of a ClinicianBeliefs 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?

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AmbiguitiesAmbiguities

• Task ambiguity

• Expectation ambiguity

• Responsibility ambiguity

• Method ambiguity

• Exception ambiguity

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Examples to Barriers Examples to Barriers

• Unclear feedback (expectation ambiguity): Presenting bloodstream infection rates in the format of 4.6 per 1000 line days is not perceived by 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

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Identifying BarriersIdentifying 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)

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Reporting FindingsReporting 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

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Action PlanAction Plan

• Form an interdisciplinary group of people (physician, nurse, inf control, resp therapy, human factors/QI expert, other) responsible with identifying barriers

• Each one conducts at least one observation and one interview.

• One clinician and one non-clinician walks 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

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ReferencesReferences

• 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).