Identifying Barriers to Evidence-basedGuideline Compliance

On the CUSP: STOP BSIOn the CUSP: STOP BSI

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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 strategies to eliminate or reduce the effects of these barriers

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Compliance with Compliance with Evidence-Based GuidelinesEvidence-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

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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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Steps of Barrier Identification and Steps of Barrier Identification and Mitigation Tool (BIM)*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

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* 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

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Step 1: Assemble the TeamStep 1: Assemble the Team

• Nursing• Infection Prevention• Managers• Senior Executives• Human factors/QI

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Step 2: Identify BarriersStep 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

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Step 2: Identify BarriersStep 2: Identify Barriers

• Ask about the process: Ask staff– Whether they are aware of/agree with the guideline– What are some of the leading problems and 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 find out 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.

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Types of BarriersTypes 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

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Ambiguity Types

• Task

• Responsibility

• Expectation

• Method

• Exception

Systems Ambiguity* as a Barrier to Systems Ambiguity* as a Barrier to Guideline ComplianceGuideline Compliance

* 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.

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Method AmbiguityMethod 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.”

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Barrier Identification FormBarrier Identification Form

CONTRIBUTING FACTORS BARRIER(S) POTENTIAL ACTIONSProviderCurrent practice habits : What do you currently do (or not do)?

Lines rarely discussed on daily interdisciplinary rounds

Add lines section to rounding form.

GuidelineEase of complying with guidelineHow does this guideline impact the workload?

SystemTools & technologies Are necessary supplies and equipment available and used appropriately?

Materials (full drapes) were missing from the line cart for an afternoon procedure(cart restocked at night).

Physical environmentHow does the unit’s layout affect compliance?

MD walked through busy hallway to wash hands at closest sink before procedure.

Make sinks more convenient?

Performance monitoring and feedback mechanismHow does the unit know it is consistently (and appropriately) applying the guideline?

No mechanism to monitor central line use and provide feedback

Review central line use at monthly unit meetings.

Other

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Step 4: Barrier Summary Step 4: Barrier Summary and Prioritizationand Prioritization

Barrier Relation to Guideline

Source Likelihood Score*

SeverityScore†

Barrier Priority Score‡

Target for this QI cycle?

Central line cart missing items (especially late in the afternoon)

Hand washing ObserveAsk

4 3 12 Yes

Full barrier precautions and clean skin with chlorhexidine

ObserveWalk

3 3 9 Yes

*Likelihood score: How likely will a clinician experience this barrier?1.Remote 2. Occasional 3. Probable 4. Frequent

†Severity score: How likely will experiencing a particular barrier lead to non-compliance with guideline?1.Remote 2. Occasional 3. Probable 4. Frequent

‡Barrier priority score = Likelihood score X Severity score

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Step 5: Development of Step 5: Development of Action PlanAction 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

Prioritized barriers

Potential Actions

Source Potential Impact Score*

Feasibility Score†

Action Priority Score‡

This QI cycle?

Action Leader

Performance Measure(Method)

Follow-up Date

Difficult for providers to cleanse their hands prior to performing central line insertion

Install sinks in rooms Observe 3 0 0 No

Place alcohol-based hand sanitizer in rooms

ObserveAsk

Walk4 4 16 Yes KM

Compliance with hand cleaning(observation)

2 months

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ReferencesReferences

• 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).