Transcript Barriers and Facilitators of Implementation

Barriers and Facilitators of
Implementation
New York Academy of Medicine
Peter Dayan, MD, MSc
December, 2012
Assessing Barriers and Facilitators: Guided by Theory
Clinical Practice Guidelines
Framework for Improvement
• Knowledge
• Attitude
• Behavior
Cabana et al. JAMA 1999
Clinical Practice Guideline Framework for Improvement
Sequence
of Behavior
Change
Barriers or
Facilitators to
Guideline
Adherence
Knowledge
Familiarity
Attitudes
Agreement:
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Awareness
Specific
guideline
Guidelines
in general
Behavior
Outcome
expectancy
Self-efficacy
External:
• Patient
• Guideline
factors
• Environmental
Motivation
Cabana et al. JAMA 1999
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
Engage the KT Players (Stakeholders):
Situation Dependent
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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
Obtain Input from Relevant
Stakeholders
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Questionnaires/surveys
Focus groups
Interviews
Direct observation
Barriers Pediatricians Face When Using Asthma
Practice Guidelines (Cabana et al, 2000)
Cabana 2001
Use of LMX for IV placement:
Stakeholder ‘Meetings’
Potential Barriers
Potential Enablers
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
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
Link Barriers to Interventions
Identified barriers
Specific interventions
Lack of knowledge
Interactive education sessions
Perception/reality mismatch
Audit and feedback
Lack of motivation
Incentives/sanctions
Beliefs/attitudes
Peer influence/opinion leaders
Systems of care
Process redesign
V. Palda,10
2007
Project Name: IV pain reduction
Project Leaders: ED pain team
KEY DRIVERS
Revision Date: 11/8/10
SMART AIM
By January 1, 2011,
70% of patients will
receive a topical
anesthetic prior to IV
placement
INTERVENTIONS
Identify patients early in ED presentation
who need IV placed or blood drawn
Flagging of patients with certain chief
complaints or vital signs for LMX placement
RN readily able to obtain order for topical
anesthetic to allow for timely placement
Set up PRN for topical anesthetic use for
above indications
ED staff buy-in of use of topical
anesthetic/belief in its effectiveness
Review of evidence for staff on topical
anesthestic for venipuncture
Easy access to materials/medications for
pain alleviation at the time of IV placement
Placement of LMX at triage and in IV cart
Increase parental awareness and
understanding of benefit of topical
anesthetic
Educational flyer for parents about LMX and
pain reduction provided in waiting area and
inform family advisory council
Correct/optimal use of topical anesthetic
by staff
In-service for nursing for optimal use of
LMX
GLOBAL AIM
Reduction in pain
experience by
children undergoing
IV placement
Copyright © 2008 Cincinnati Children’s Hospital Medical Center; all rights reserved.
Summary: Involvement Leads to Buy-in
Extras