Barriers and Facilitators of Implementation

New York Academy of MedicinePeter Dayan, MD, MSc

December, 2012

Assessing Barriers and Facilitators: Guided by Theory

• Knowledge• Attitude• Behavior

Cabana et al. JAMA 1999

Clinical Practice Guidelines Framework for Improvement

Clinical Practice Guideline Framework for Improvement

Sequence of Behavior Change

Barriers orFacilitators to GuidelineAdherence

Familiarity

Knowledge

External:• Patient• Guideline

factors• Environmental

Agreement:• Specific

guideline• Guidelines

in generalAwareness

Attitudes Behavior

Motivation

Self-efficacy

Outcome expectancy

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

• 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

• 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

1. Lack of familiarity w/ topical anesthetics2. Belief that topical anesthetic “hides veins”3. Some patients can not wait for topical anesthetic to work4. Some patients don’t need topical anesthetic5. Concern that it can’t be used with ethyl chloride spray6. Ability to predict who needs an IV7. Medication not available at triage8. 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 LMX3. LMX placed in multiple locations4. Huddles and email reminders5. Experienced nurses good at predicting

who will need an IV6. Families feel that when applied, we are

doing something for them

10

Link Barriers to InterventionsIdentified 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, 2007

KEY DRIVER DIAGRAMProject Name: IV pain reduction Project Leaders: ED pain team

SMART AIM

KEY DRIVERS INTERVENTIONS

By January 1, 2011, 70% of patients will

receive a topical anesthetic prior to IV

placement

ED staff buy-in of use of topical anesthetic/belief in its effectiveness

Review of evidence for staff on topical anesthestic for venipuncture

Set up PRN for topical anesthetic use for above indications

Flagging of patients with certain chief complaints or vital signs for LMX placement

Revision Date: 11/8/10

Copyright © 2008 Cincinnati Children’s Hospital Medical Center; all rights reserved.

Reduction in pain experience by

children undergoing IV placement

GLOBAL AIM

RN readily able to obtain order for topical anesthetic to allow for timely placement

Identify patients early in ED presentation who need IV placed or blood drawn

Easy access to materials/medications for pain alleviation at the time of IV placement

Increase parental awareness and understanding of benefit of topical anesthetic

Correct/optimal use of topical anesthetic by staff

Placement of LMX at triage and in IV cart

Educational flyer for parents about LMX and pain reduction provided in waiting area and inform family advisory council

In-service for nursing for optimal use of LMX

Summary: Involvement Leads to Buy-in

Extras