On the CUSP: STOP BSI Identifying Barriers to Evidence-based Guideline Compliance © 2009

Identifying Barriers to Evidence-based
Guideline Compliance
© 2009
Learning Objectives
• To learn about the different types of barriers to
guideline compliance
• To learn how to identify the barriers to guideline
• To understand how to develop a process to
eliminate or reduce the effects of these barriers
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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
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Ask 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
• 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 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
• 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 catheterrelated bloodstream infections? What are the common lapses
in compliance?
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• 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
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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)
• 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 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
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• Task ambiguity
• Expectation ambiguity
• Responsibility ambiguity
• Method ambiguity
• Exception ambiguity
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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
• Central line cart is not stocked regularly
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Identifying Barriers
• Conduct preliminary interviews to understand causes of noncompliance. Is guideline compliance intentional or nonintentional?
− 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 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 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
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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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
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).
© 2009