On the CUSP: STOP BSI
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
compliance
• To understand how to develop a process to
eliminate or reduce the effects of these barriers
© 2009
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
© 2009
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
guideline?
• What are some of the strategies and tools you have
implemented to improve compliance with this guideline in
your unit?
© 2009
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
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 catheterrelated bloodstream infections? What are the common lapses
in compliance?
© 2009
Observe
• 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
© 2009
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?
© 2009
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
© 2009
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
these?
© 2009
Ambiguities
• Task ambiguity
• Expectation ambiguity
• Responsibility ambiguity
• Method ambiguity
• Exception ambiguity
© 2009
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
© 2009
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)
© 2009
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
© 2009
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
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
© 2009
References
•
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).
© 2009