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The Joint Commission Journal on Quality and Patient Safety Tool Tutorial

A Practical Tool to Identify and Eliminate Barriers to Compliance with Evidence-Based Guidelines Readers may submit Tool Tutorial inquiries and submissions to Steven Berman at [email protected].

Ayse P. Gurses, Ph.D.; David J. Murphy, M.D.; Elizabeth A. Martinez, M.D., M.H.S.; Sean M. Berenholtz, M.D., M.H.S.; Peter J. Pronovost, M.D., Ph.D.

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espite major efforts to improve patient safety, a significant number of patients continue to suffer preventable 1–3 harm. Much of this harm results from a failure to standardize care processes to ensure that patients receive evidence-based interventions.4 Guidelines summarize evidence to help ensure patients receive recommended interventions. However, compliance with evidence-based guidelines varies anywhere from 20% to 100%.4–7 Research has identified many types of barriers to guideline compliance related to providers (for example, unfamiliarity with a guideline,8 disagreement with guidelines9), specific guideline characteristics (ease of complying with a particular guideline, level of evidence that supports a particular guideline8), and system characteristics (systems ambiguity,10 ineffective communication,11 high work load,12 lack of necessary supplies and equipment13,14). However, the relative contributions of these barriers to noncompliance often differ on the basis of both the specific evidence-based practices and the local culture.8,15 We have successfully applied a conceptual model for translating evidence into practice.16,17 The model converts evidence into behaviors and depends on a process that identifies local barriers to implementing those behaviors. Far too often, interventions to overcome barriers are implemented without investigating the actual reasons for guideline avoidance or poor compliance.18 For example, if knowledge of a guideline is not a barrier, further education of staff will, most likely, not improve guideline compliance. A systematic approach to identify, prioritize, and remove barriers to evidence-based guidelines is critical to successfully and efficiently improve quality and safety of health care. This article describes the barrier identification and mitigation (BIM) tool, which provides a practical and interdisciplinary approach to identifying barriers to guideline compliance and to implementing actions to eliminate or mitigate the effect of these barriers. 526

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Tool Description The purpose of the BIM tool is to aid quality and safety improvement efforts to translate evidence into practice by identifying and removing or mitigating barriers to guideline and/or intervention compliance. This tool includes a brief user’s guide (Table 1, below); an overview of the five-step tool process (Table 2, page 527); and the tool to record barriers (Table 3, page 528), summarize and prioritize barriers (Table 4, page 529), and take action to remove or mitigate barriers (Table 5, page 530).

Table 1. Barriers Identification and Mitigation (BIM) Tool User’s Guide Problem Statement Reliable use of evidence-based guidelines can significantly improve patient safety. Yet, guideline compliance tends to be low and highly variable within and between clinical units. Barriers prevent the consistent and appropriate application of evidencebased guidelines in clinical practice; these barriers are not well understood. Purpose of Tool This tool is intended to aid quality and safety improvement efforts by identifying and removing or mitigating barriers to guideline compliance or the reliable use of evidence-based therapies. Who Should Use This Tool? This tool may be used by interdisciplinary teams in a variety of health care settings seeking to improve compliance with evidencebased guidelines or seeking to translate evidence into practice. How to Use This Tool The BIM tool is best applied in the context of a comprehensive quality and safety improvement effort, such as the Comprehensive Unit Based Safety Program (CUSP) program. This tool should be used periodically (every three to six months or so) to identify barriers if compliance with a guideline or therapy is poor.

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The Joint Commission Journal on Quality and Patient Safety Table 2. Steps of Barrier Identification and Mitigation (BIM) Tool Step 1. Assemble the Interdisciplinary Team The interdisciplinary team should be composed of frontline care workers (e.g., nurses, physicians, technicians), administrators, and human factors and quality improvement specialists. Step 2. Identify Barriers This step includes three methods of data collection that can be performed in parallel. Each investigator collects data independently using these collection methods and records both the barriers and possible corrective actions on Table 3. This step may take 2–6 hours. Method 1: Observe the Process: Observe staff attempting to use the guideline and record ■ Steps skipped ■ Work-arounds (other process steps) ■ Why it is difficult to comply (i.e., guideline barriers) ■ Factors that support compliance (i.e., guideline facilitators) Method 2: Ask about the Process: Ask staff through interviews or short questionnaires whether they ■ Are aware of the guideline ■ Agree with the guideline (i.e., Do staff think that the guideline is appropriate for their patients?) ■ Have any suggestions to improve compliance with guideline Method 3: Walk the Process ■ Try to comply with the guideline using simulation or, if appropriate, under real circumstances. Continue collecting data until no new barriers are identified upon new data collection and a comprehensive understanding of current practices used and barriers to guideline compliance is achieved. Step 3. Summarize Barriers (Table 3) A team member compiles the data collected by several investigators on Table 3. Step 4. Prioritize Barriers (Table 4) The interdisciplinary team reviews and discusses the barrier summary. The team prioritizes barriers based on two criteria: 1. Likelihood: probability of experiencing a barrier 2. Severity: probability that barrier will lead to noncompliance Step 5. Develop an Action Plan for each targeted barrier (Table 5) The interdisciplinary team ■ Reviews potential actions suggested by observers in Step 2 ■ Identifies additional potential actions (may use formal brainstorming techniques) ■ Selects individual actions for the next improvement cycle based on two criteria: 1. Feasibility: probability the action can be successfully implemented based on resources currently available 2. Potential impact: probability that this action will improve compliance ■ Sets a leader, dates to monitor progress, and appropriate measures for each action

Tool Application to Quality and/or Safety Health care organizations are working to improve patient safety and quality of care, but few efforts have addressed the inadequate translation of research evidence into clinical practices.19,20 Thus, patients in the United States on average receive recommended care only 55% of the time.4 By systematically identifying and mitigating barriers to guideline compliance, the BIM tool may increase the reliable delivery of evidence-based therapies to patients. More reliable delivery of recommended care can improve the quality of health care and patient outcomes.

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There are a variety of theoretical models to improve guideline compliance. The BIM tool is based on six theoretical models from different fields (medicine,8 human factors and systems engineering,10,21 psychology,22 health education,23 social marketing,24,25 rural sociology26) that explain guideline compliance. On the basis of these models, we grouped factors that affect guideline compliance into three major categories: provider characteristics, guideline characteristics, and system characteristics. Table 3 uses these three categories, as follows, to structure the barrier identification process: ■ Provider characteristics may involve inadequate knowlVolume 35 Number 10


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The Joint Commission Journal on Quality and Patient Safety Table 3. Barrier Identification Form Evidence-based guideline: When inserting and maintaining central venous catheters, providers should: (1) wash their hands, (2) use full-barrier precautions during catheter insertion, (3) clean skin with chlorhexidine, (4) avoid the femoral site if possible, and (5) remove unnecessary catheters to minimize the risk of central line–associated bloodstream infections. Mode of data collection: Observation Investigator: S. Jones, R.N. Clinical Unit: ICU A CONTRIBUTING FACTORS

BARRIER(S)

POTENTIAL ACTIONS

Lines rarely discussed on daily interdisciplinary rounds.

Add lines section to rounding form.

Provider Knowledge of the guideline What are the elements of the guideline? Attitude regarding the guideline What do you think about the guideline? Current practice habits What do you currently do (or not do)? Perceived compliance with the guideline How often do you do everything right? Guideline Applicability to patient population How often does the guideline apply to the patients on the unit? Evidence supporting the guideline How strongly does the evidence support the guideline? Ease of complying with guideline How does this guideline impact the work load? System Task Who is responsible for each aspect of the guideline? Tools & technologies Are necessary supplies and equipment available and used appropriately?

Materials (full drapes) were missing from the line cart for an afternoon procedure (cart restocked at night).

Decision support (e.g., checklists, order sets) How often are aids available and used? Physical environment How does the unit’s layout affect compliance?

Physician walked through busy hallway to wash hands at closest sink before procedure.

Make sinks more convenient.

No mechanism to monitor central line use and provide feedback

Review central line use at monthly unit meetings.

Organizational structure (e.g., staffing, policies) How does the organizational structure influence compliance? Administrative support How does the administration visibly (and substantially) influence guideline compliance? Performance monitoring and feedback mechanism How does the unit know it is consistently (and appropriately) applying the guideline? Unit culture How does the unit culture influence compliance? Other

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The Joint Commission Journal on Quality and Patient Safety Table 4. Barrier Summary and Prioritization Likelihood Score*

Severity Score†

Barrier Priority Score‡

Target for this QI§ cycle?

Observe Ask

4

3

12

Yes

Full barrier precautions and clean skin with chlorhexidine

Observe Walk

3

3

9

Yes

No mechanism to ensure that clinicians review line necessity on a daily basis

Remove unnecessary catheters.

Observe Ask Walk

3

4

12

Yes

No mechanism to monitor central line use and provide feedback

Remove unnecessary catheters.

Observe

4

2

8

No

Barrier

Relation to Guideline

Source

Difficult for providers to cleanse their hands prior to performing central line insertion

Hand washing

Central line cart missing items (especially in the late afternoon)

*Likelihood score: How likely will a clinician experience this barrier? 1. Remote 2. Occasional 3. Probable 4. Frequent † Severity score: How likely will experiencing a particular barrier lead to noncompliance with guideline? 1. Remote 2. Occasional 3. Probable 4. Frequent ‡ Barrier priority score = Likelihood score ⫻ Severity score. The higher the priority score for a barrier, the more critical it is to eliminate or mitigate the effects of that barrier. Teams should consider setting a threshold barrier priority score for determining which barriers to target. In this example, the team decided to focus on the barriers that have a priority score ≥ 9.

§ Quality improvement.

edge or awareness about the guideline, disagreement with the guideline, and reluctance of care providers to change their current practice habits. ■ Guideline characteristics may include guidelines not relevant for a particular patient population, inadequacies in the level of scientific evidence to support the guideline, and ambiguity of tasks and roles in the guideline. ■ System characteristics may involve problems related to the tasks performed, tools and technologies used, physical environment, and organizational structure and culture. Barriers to complying with evidence-based guidelines emerge from these three major characteristics and their interactions. The BIM tool can also be used by researchers and educators in the areas of human factors, patient safety, and quality. For example, it may facilitate research to further characterize barriers to the effective translation of evidence into practice and the evaluation of new approaches to overcoming these barriers. Furthermore, using the BIM tool in classroom or practical settings can provide students with a valuable experience on how system and other factors may impede or facilitate the consistent translation of evidence into clinical practice.

The BIM tool is best applied in the context of a larger framework, such as the Comprehensive Unit-Based Safety Program (CUSP),17,27,28 which addresses the local culture of safety and uses a structured approach to translate evidence into practice.16 Used in conjunction with CUSP, the BIM tool fits nicely in identifying and mitigating the effects of barriers to complying with guidelines, hence improving quality and safety of care. By combining a model to translate evidence into practice with CUSP, our research group substantially reduced central line–associated bloodstream infections (CLABSIs) in 103 Michigan ICUs.17 The BIM tool should be used periodically as part of continuous improvement efforts in health care organizations. It should be used iteratively because health care systems are dynamic and new technologies or policies may introduce new or resurface old barriers and because some interventions to remove barriers may not be sustainable over time.

Tool Applications Settings

How-To

This tool can be applied in any inpatient (for example, ICU,

Practical and straightforward, the BIM tool can be used by

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general surgical floor) or outpatient (for example, cardiology or ophthalmology clinic) care area. It can also be applied as part of a quality improvement effort or research project.

Best Application

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The Joint Commission Journal on Quality and Patient Safety Table 5. Development of Action Plan

Prioritized Barriers

Potential Actions

Source

Potential Impact Score*

Difficult for providers to cleanse their hands prior to performing central line insertion

Install sinks in rooms where the procedures are performed.

Observe

3

0

0

No

Place alcohol-based hand sanitizer in rooms where procedures are performed.

Observe Ask Walk

4

4

16

Yes

KM

Compliance with hand cleaning (observation)

Two months

Brainstorm

3

3

9

Yes

TC

Number of missing items (cart inspection)

Three months

Increase number of drapes in cart.

Ask

2

4

8

Yes

TC

Number of missing items (cart inspection)

Three months

Add lines section to rounding form.

Observe Ask

3

3

9

Yes

RO

Line-days per patient (chart review)

One month

Brainstorm

3

1

3

No

Central line cart missing items (especially in the late afternoon)

No mechanism to ensure that clinicians review line necessity on a daily basis

Revise cart stocking schedule and review with materials support personnel.

Develop electronic monitoring system including catheter location and duration.

Feasibility Score†

Action Priority Score‡

Select for this QI cycle?

Action Leader

Performance Measure Follow-up (Method) Date

*Potential impact score: What is the potential impact of the intervention on improving guideline compliance? 0. No impact 1. Low 2. Moderate 3. High 4. Very high † Feasibility score: How feasible is it to take the suggested action? 0. Not feasible 1. Low 2. Moderate 3. High 4. Very high ‡ Action priority score = Potential impact score ⫻ Feasibility score Teams should consider setting a threshold action priority score for which actions to pursue during the upcoming quality improvement (QI) cycle.

frontline clinicians and nonclinicians to identify and analyze the barriers in their own care settings and to develop action plans to address these barriers. The five-step process does require a time commitment and project management. In Step 1, an interdisciplinary team composed of clinicians, administrators, and support staff in the area where the guideline is to be applied (for example, an intensivist and critical care nurse if an intensive care unit [ICU] guideline) and experts in content knowledge, human factors, and quality is assembled. Building a diverse team early on is critical to more completely characterize local barriers and to generate potential actions to facilitate subsequent implementation. A group-consensus approach should be used to assign team members to subsequent steps and to select techniques.29 In Step 2, several team members work independently to identify barriers to guideline compliance in the clinical area targeted. They use the following three methods to collect data and 530

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continue collecting data until no new information is discovered; this process will take 2 to 6 hours: ■ Observe a few clinicians engaged in completing the relevant tasks. ■ Ask about the problems they face and potential solutions in carrying out the guideline through informal discussions, focus groups, or brief survey. ■ Walk the process by consciously following the guideline during clinical practice (or simulations) and document barriers to compliance. Table 3 provides a structured form to help facilitate data collection. In Step 3, the assigned team member compiles the barrier data collected by all team members on the barrier identification form (Table 3), summarizes this information in columns 1 through 3 of Table 4, and adds any suggestions provided by observers to improve compliance to Table 5.

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The Joint Commission Journal on Quality and Patient Safety In Step 4, the team systematically reviews the barriers in Table 4 and rates each on the likelihood of the barrier occurring in the unit (likelihood score) and the probability that, if encountered, it will lead to guideline noncompliance (severity score). Each is scored from 1, indicating a low likelihood or severity, to 4, indicating a high likelihood or severity. The priority score for each barrier is calculated by multiplying the likelihood and severity scores. Higher priority scores reflect greater urgency for eliminating or mitigating the barrier. Set a threshold to decide which barriers to target (for example, barriers with a priority score > 9) or target the top three barriers. In Step 5, the team lists potential actions to mitigate the selected barriers on Table 5 and rates each action on the basis of the potential impact of the action on the barrier, if successfully implemented (potential impact score), and the feasibility of implementing the action in the unit (feasibility score). It is critical to closely examine the feasibility of implementing an action. The same four-point scoring system is used. The priority score for each action is calculated by multiplying the impact and feasibility scores; the higher the score the higher the priority. Each action requires an appropriate leader, measures and methods of evaluation, and follow-up dates to evaluate progress.

Output In the example of a completed BIM shown in Tables 3 through 5, the rate of CLABSIs in “ICU A” is worse than expected despite the unit’s policy to follow specific evidence-based practices recommended in the guideline. An interdisciplinary team is assembled, including critical care and infectious disease physicians, ICU and infectious disease nurses, technicians, the ICU administrator, and the hospital quality officer. Ms. Jones, an infectious disease nurse, outlined her observations. She noted, as listed as barriers in Table 3, that lines were rarely discussed during rounds, supplies for full-barrier protection were missing from the line cart, the physician had to walk down the hall to wash his hands, and there was no mechanism to monitor central lines and provide feedback. The staff being observed suggested that lines be added to the form for discussion during rounds, that sinks be more convenient, and that line use be reviewed during monthly unit meetings. At this stage, typically, multiple people would collect data. The assigned team member compiled and summarized the barriers from Table 3, noted the relation of the barrier to the guideline and the source of the data supplied, as shown in Table 4. The entire team met and rated the barriers, on the basis of which they decided to take action on the barriers related to

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hand washing, sterile precautions, and removal of unnecessary lines. The team discussed and scored potential actions, as shown in Table 5, to address the targeted barriers. Although installing sinks in patient rooms was suggested for hand washing, this would be costly, logistically difficult, and not feasible. Instead, alcohol-based hand sanitizers were placed outside each room. Compliance with hand washing was measured through observation and evaluated in two months. To resolve the issue of missing supplies from the line cart, more drapes were stocked, and the schedule to restock the cart was reviewed with centralsupply personnel. The cart was inspected periodically to count the number of missing items, and the interventions were evaluated in three months. To improve review of line necessity, a section was added to the rounding form to discuss lines, and the number of line-days per patient was measured through chart review and evaluated in one month. The suggestion to develop an electronic monitoring system for lines received a low priority score and was not addressed.

Results and Lessons to Date An earlier version of the BIM tool was successfully used in our collaborative cohort study, the ICU Keystone Project, which was conducted in 103 Michigan ICUs and resulted in significant reduction of CLABSIs.17 The tool was instrumental in identifying a variety of provider, guideline, and system barriers to compliance with the evidence-based guidelines and in developing/implementing action plans to eliminate these barriers. For example, using the BIM tool, we discovered that many ICUs lacked chlorhexidine in their central line kits, making compliance with using chlorhexidine difficult. ICUs had not ordered central kits that contained all the equipment and supplies needed to comply with the CLABSI checklist. The BIM tool was revised on the basis of the suggestions of participants in this study to be more explicit and to include ratings of barriers and interventions. The BIM tool is also being used in a large-scale collaborative designed to improve surgical safety in 84 Michigan hospitals. For example, we used it to identify and target a variety of barriers to reduce mislabeled specimens: inadequate provider training, no mechanism to ensure that clinicians review specimens before leaving the operating room at the end of a case, and unstandardized formats of specimen labels and requisition forms.30 Given these findings, we provided teams with materials to educate frontline providers, encouraged teams to standardize specimen label and requisition forms, and asked providers to verify specimen information during debriefings.31

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The Joint Commission Journal on Quality and Patient Safety We are currently using the BIM tool to identify and prioritize barriers to compliance with (1) CLABSI prevention guidelines as part of the STOP BSI project (http://www.safercare. net/) and (2) evidence-based red-blood-cell transfusion practices in ICUs. The BIM tool can be used as a teaching tool in a medical, nursing, or public health school curriculum to demonstrate how barriers can impede the consistent translation of evidence into clinical practice. For example, it was used in a mandatory course in Fall 2007 on health care quality and safety at the University of Minnesota; students implementing the tool in various medical care settings (ICUs, general floor, emergency departments [EDs], and community clinics). For example, one project identified “providers’ reluctance to change their current practice habits” as a barrier to compliance with the pediatric asthma guidelines in the ED. On the students’ recommendation, a multidisciplinary meeting was held with ED care providers and quality improvement specialists to discuss issues associated with the asthma guidelines and to develop an action plan. In Winter 2010, the BIM tool will be included in the patient safety course (required for second-year medical students) at the Johns Hopkins University.

Contact Us Please contact Ayse P. Gurses at [email protected].

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The authors thank Christine G. Holzmueller, B.L.A., for her assistance in preparing this manuscript.

Ayse P. Gurses, Ph.D., is Assistant Professor, Department of Anesthesiology and Critical Care Medicine, Quality and Safety Research Group, Johns Hopkins University School of Medicine, Baltimore. David J. Murphy, M.D., is Clinical Fellow, Department of Medicine, Division of Pulmonary and Critical Care Medicine. Elizabeth A. Martinez, M.D., M.H.S., and Sean M. Berenholtz, M.D., M.H.S., are Associate Professors, Department of Anesthesiology and Critical Care Medicine, Quality and Safety Research Group. Peter J. Pronovost, M.D., Ph.D., is Professor, Department of Anesthesiology and Critical Care Medicine, Quality and Safety Research Group, and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore; and a member of The Joint Commission Journal on Quality and Patient Safety's Editorial Advisory Board.

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