1. Barriers and Facilitators of Implementation New York Academy of Medicine Peter Dayan, MD, MSc December, 2012

3. Assessing Barriers and Facilitators: Guided by Theory Knowledge Attitude Behavior Cabana et al. JAMA 1999 Clinical Practice Guidelines Framework for Improvement

4. Clinical Practice Guideline Framework for Improvement Sequence of Behavior Change Barriers or Facilitators to Guideline Adherence Familiarity Knowledge External: Patient Guideline factors Environmental Agreement: Specific guideline Guidelines in general Awareness AttitudesBehavior Motivation Self-efficacy Outcome expectancy Cabana et al. JAMA 1999

5. Assessing Barriers and Facilitators: The Practical Side Identify relevant stakeholders Obtain input from relevant stakeholders Use framework (theory) to categorize barriers and facilitators Prioritize the barriers and facilitators – Modifiable? Choose interventions (carefully) that target the barriers and facilitators

6. Engage the KT Players (Stakeholders): Situation Dependent Patients Practitioners Policy makers (local and beyond) Health care teams (e.g. ED QI team) Healthcare organizations and systems Public (community) Press …and investigators Participation Leads to Change

7. Obtain Input from Relevant Stakeholders Questionnaires/surveys Focus groups Interviews Direct observation

8. Barriers Pediatricians Face When Using Asthma Practice Guidelines (Cabana et al, 2000) Cabana 2001

9. Use of LMX for IV placement: Stakeholder ‘Meetings’ Potential Barriers 1. Lack of familiarity w/ topical anesthetics 2. Belief that topical anesthetic “hides veins” 3. Some patients can not wait for topical anesthetic to work 4. Some patients don’t need topical anesthetic 5. Concern that it can’t be used with ethyl chloride spray 6. Ability to predict who needs an IV 7. Medication not available at triage 8. Ability to obtain an order for the LMX Potential Enablers 1.List of chief complaints for patients who would benefit from early application 2.Easily accessible place for LMX 3.LMX placed in multiple locations 4.Huddles and email reminders 5.Experienced nurses good at predicting who will need an IV 6.Families feel that when applied, we are doing something for them

10. 10 Link Barriers to Interventions Identified barriersSpecific interventions Lack of knowledgeInteractive education sessions Perception/reality mismatchAudit and feedback Lack of motivationIncentives/sanctions Beliefs/attitudesPeer influence/opinion leaders Systems of careProcess redesign V. Palda, 2007

12. Summary: Involvement Leads to Buy-in

13. Extras