AARC Barriers to Protocol ImplementationSurvey Results

A Project of the AARC Protocol Implementation Committee

2008

Slides developed to adjunct lectures supporting the use of respiratory care protocols

Survey Background

• In order to better develop a plan for the implementation and use of protocols the committee recognized that barriers exist

• Survey tools were developed to assess these barriers and perceptions

• Separate surveys were developed for both the Manager and Staff Therapist

• This slide presentation was developed from those surveys and is intended to assist in understanding the barriers and developing successful strategies to implement protocols

Protocol Definition

• For the purpose of both the Manager and Staff surveys, protocols were defined as: – Initiation or modification of a patient care plan

following a predetermined structured set of physician orders, instructions or interventions in which the therapist is allowed to initiate, discontinue, refine, transition, or restart therapy as the patient's medical condition dictates.

• Note: This definition should not be confused with programs that include discontinuation of therapy without a reorder, flagging therapy for physician reorder, standing orders or policies that dictate therapy durations.

Respondents Region - Manager Survey

459 respondents (post cards and email)

In which U.S. census region is your hospital located?

New England

Middle Atlantic

East North Central

West North Central

South Atlantic

East South Central

West South Central

Mountain

Pacific

Demographics – Manager Survey

Location of your hospital

0%

5%

10%

15%

20%

25%

30%

35%

40%

1

Rural

Suburban

Urban

Hospital Type - Manager Survey

Describe your hospital's type of ownership

0% 10% 20% 30% 40% 50% 60% 70%

Government-Non-Federal

Government-Federal

Non-Government not-for-profit

Investor owned (for-profit)

Number of staffed beds supported by your hospital

27%

23%

26%

24%

21% 22% 23% 24% 25% 26% 27% 28%

Less than 100

101-200

201-400

401 or more

The majority were not forprofit hospitals

Evenly split betweensmall and large hospitals

Department Profile - Manager SurveyWhat is the total number of respiratory therapist FTEs?

0%

5%

10%

15%

20%

25%

30%

35%

Less than 10 11 25 26-50 51-75 76-100 More than 100

Does your hospital have protocols in place as described in the definition above?

Yes

No

Mostly hospitals with < 25 FTEs

The majority have at least one protocol as described

Protocol Use - Manager Survey

Does your hospital have protocols in place as described in the definition above?

0% 10% 20% 30% 40% 50% 60%

1 to 5

5 to 10

More than 10

What is your estimate of the percent of respiratory therapy provided by protocol at your institution?

0% 5% 10% 15% 20% 25% 30% 35% 40%

0-25

26-50

51-75

76-100

Not applicable

The majority of hospitals do not have a comprehensive protocol program.

Less than 50% of care is provided by protocols despite the evidence that protocols improve outcomes and reduce cost.

Types of Protocols in Place - Manager Survey

64%

37%33%

50%

24%

58%

20%

0%

10%

20%

30%

40%

50%

60%

70%

Oxygen Bronchialhygiene

Lunghyperinflation

Bronchodilatortherapy

Disease-based Mechanicalventilation

Not applicable

An even mix of complex and simple protocols.

Medical Staff Order Practices - Manager Survey

Estimate the percent of your medical staff who routinely order respiratory therapy by protocol

0%5%

10%

15%20%25%30%

35%40%45%

0-25 26-50 51-75 76-100 Not applicable

If you add the N/A (meaning they don’t have protocols established for physicians to order) to the 0-25% category, that is the majority of physicians.

Manager Perception of Medical Staff Opinion

0%

5%

10%

15%

20%

25%

30%

35%

40%

Extremelysignificant

Somewhatsignificant

Notsignificant

Staff Physicians

Are opposed

Are concerned that the therapistsdon't have the skills required

Are unaware of the clinical andeconomic benefits

Perceive they would lose control

Many physicians are opposed or perceive they would lose control.

• The medical directors of departments

• The managers of the department

• The nurses

• The administrators

The Manager Survey Indicates the Following are NOT Barriers

Managers Perceive the Barrier as …

• It was apparent from the survey that the medical directors and managers felt that a portion of the barrier was that RT didn’t have the skills to function under protocols

• That perception MUST change…..

Staff Surveys

• Surveys were emailed to all identified as “staff” therapists in the AARC member database with1705 responses

• The following slides represent the perceptions of staff therapist of administration, medical staff, nurses and themselves

Respondents Region - Staff Survey

U.S. Census Region

5%

6%16%

14%

10%23%

6%

10%10%

#1 New England

#2 Middle Atlantic

#3 East North Central

#4 West North Central

#5 South Atlantic

#6 East South Central

#7 West South Central

#8 Mountain

#9 Pacific

Demographics – Staff Survey

Hospital Location

0%

10%

20%

30%

40%

50%

Rural Suburban Urban

Rural

Suburban

Urban

Staffed Bed Size – Staff Survey

0%

5%

10%

15%

20%

25%

30%

35%

40%

Less than 100 101-200 201-400 401 or more

Hospital Type - Staff Survey

0% 20% 40% 60%

Government-Non-Federal (state, county,city-county, community-

owned, etc.)

Non-Government not-for-profit (church affiliated, etc.)

Hospital Type of Ownership

Is this hospital affiliated with a medical school?

0%

10%

20%

30%

40%

50%

60%

70%

Yes No

Same as manager’s survey, the majority are not-for-profit.

Most are not affiliated with a medical school.

Investor Owned for Profit

Government owned

Do You Have Protocols? - Staff Survey

Protocols Established

0% 10% 20% 30% 40% 50% 60% 70% 80%

Yes

No

Although staff reports most departments having protocols, the manager survey shows most do not have a comprehensive protocol system.

Staff Perception of Managers as Barriers

Staff do not view a manager as a significant barrier.

Staff Perceptions of Medical Staff as Barriers

0 100 200 300 400 500 600

Are opposed to care being deliveredby protocol.

Are concerned that the therapists don'thave the skills required to implement

protocols.

Are unaware of the clinical andeconomic benefits of implementing

protocols.

Perceive they would lose control of thetreatment provided to their patients if

protocols were implemented.

1-Not significant

2

3

4

5-Extremely significant

Staff perceive physicians sense a loss of control as a significant barrier.

Staff Perception of Medical Directors as Barriers

0 100 200 300 400 500 600

Is opposed to care being delivered byprotocol.

Is concerned that the therapists don't havethe skills required to implement protocols.

Is unaware of the clinical and economicbenefits of implementing protocols.

Percieves they would lose control of thetreatment provided to their patients if

protocols were implemented.

1-Not significant2345-Extremely significant

Medical directors do not pose a significant barrier to protocols

Staff Perceptions of Nurses as Barriers

0

100

200

300

400

500

600

Is opposed to carebeing delivered by

protocol.

Is concerned that thetherapists don't havethe skills required toimplement protocols.

Is unaware of theclinical and economic

benefits ofimplementing

protocols.

5-Extremely significant

4

3

2

1-Not significant

Nurses are not perceived as a significant barrier for most staff.

Staff Perception of Respiratory Therapist as Barriers

0100200300400500600700800

Are opposed tocare beingdelivered by

protocol.

Don't have theskills required to

implementprotocols.

Are unaware ofthe clinical and

economicbenefits of

implementingprotocols.

Are concernedthat staff wouldbe reduced if

protocols wereimplemented.

5-Extremely significant

4

3

2

1-Not significant

Respiratory therapists do not view themselves as a significant barrier

Willingness to Learn Another Skill if Protocols Reduce the Need for RTs? – Staff Survey

Are you willing to learn other skills?

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

This demonstrates RTs adaptability and should serve the profession well in the future.

Do RTs View Themselves as Barriers? – Staff Survey

Are RTs themselves are barrier?

0% 20% 40% 60% 80%

Yes

No

Therapists do not view themselves as the barrier to protocols

Staff Survey Conclusions

• Medical staff are perceived as the most significant barrier to protocols.

• Most RT staff do not view themselves as significant barriers

• Staff therapists do not view administrators and manager as significant barriers

• Nearly all RTs are willing to learn additional skills if adoption of protocols will assure that patients receive appropriate care

A Note from the AARC Protocol Implementation Committee

• Please use these slides in assessing potential barriers when implementing programs in your facility

• You should assess if the specific barriers at your hospital are different, so you can develop a successful strategy to overcome those barriers

• For additional information visit the Protocol Resources at www.aarc.org

• You can also contact the Chair of the Protocol Implementation Committee for a complete file of the Manager and Staff Surveys