1. © 2009 On the CUSP: STOP BSI Identifying Barriers to Evidence-based Guideline Compliance

2. © 2009 Learning Objectives To identify different types of barriers to guideline compliance To apply knowledge to identify real barriers to guideline compliance in participating units To describe a process to eliminate or reduce the effects of these barriers To discuss barriers and solutions in a cross-team group setting

3. © 2009 Remove unnecessary lines Wash hands prior to procedure Use maximal barrier precautions Clean skin with chlorhexidine Avoid femoral lines Evidence-based Behaviors to Prevent CLABSI

4. © 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?

5. © 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 catheter- related bloodstream infections? What are the common lapses in compliance?

6. © 2009Observe 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

7. © 2009 Try out the Guideline Triability of a guideline increases 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?

8. © 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

9. © 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?

10. © 2009Ambiguities Task ambiguity Expectation ambiguity Responsibility ambiguity Method ambiguity Exception ambiguity

11. © 2009 Examples of 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

12. © 2009 Identifying Barriers Conduct preliminary interviews to understand causes of non- compliance. Is guideline compliance intentional or non- intentional? −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)

13. © 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

14. © 2009 Action Plan Form an interdisciplinary group of people (physician, nurse, inf control, resp therapy, human factors/QI expert, other) responsible for identifying barriers. Each one conducts at least one observation and one interview. People from two different disciplines walk 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.

15. © 2009References 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).

16. © 2009 Interactive Activity Pair older teams with new teams Pick one of 3 discussion topics Group discussion (~30 minutes) Groups report out on barriers and solutions (~10 minutes) 16

17. © 2009 Discussion Groups Not enough engagement Not enough time Not enough communication 17

18. © 2009 Not Enough Engagement 18 What barriers has your team faced engaging this group? How have/could you respond? What worked or didn’t? Why? With regards to: – Senior executives – Physicians – Nurses – Quality officers – Infection preventionists – Others

19. © 2009 Not Enough Time How do you overcome barriers to senior leadership availability? How do you overcome barriers to unit-level availability to do the work? How do you manage data within the time constraints of your work? 19

20. © 2009 Not Enough Communication How do you create a communication “vessel”? How do you communicate the goal and the process for getting there? How do you empower staff to speak up? How do you set clear expectations avoiding role and task ambiguity? How do you foster using clear and concise language? 20