Session number: 1109
Abstract title: Providers' Perceptions About Clinical Practice Guideline Implementation
Author(s):
ML Guihan - Midwest Center for Health Services and Policy Research
BN Simmons - James A. Haley VA Hospital
AL Nelson - James A. Haley VA Hospital
H Bosshart - Augusta VA Medical Center
SP Burns - VA Puget Sound Health Care System
Objectives: Prior to development of an intervention to implement spinal cord injury (SCI) clinical practice guidelines (CPGs), providers were asked to share their perceptions regarding barriers and facilitators to implementing two SCI guidelines (thrombo-embolism [DVT] and neurogenic bowel) at their sites.
Methods: A total of 10 focus groups with 75 SCI staff (including physicians, nurses, dietary, physical therapy and social workers) were conducted at 5 VA sites nationally in June 1999. For each recommendation, providers were asked: “What factors could prevent you from making sure that a patient receives CPG recommended care?” and then, “How could these factors be overcome?” Woolf's (2000) framework was used to classify participants’ comments into one of four categories, including lack of: (1) knowledge, (2) acceptance, (3) ability or (4) systematic reminders.
Results: : The largest set of barriers to guideline implementation fell into the “lack of ability” category (n=166). Lack of a reminder system was cited as the next most frequent barrier (n=30), followed by “disagreement with the guideline or specific recommendations” (n=26). Provider lack of knowledge was the least frequently cited barrier to implementation (n=20). Results varied between the two guidelines. Lack of knowledge of (n=14 vs. n=6), disagreement with (n=16 vs. n=10) and lack of reminder systems were cited more frequently as obstacles to implementation for DVT, whereas inability was a more frequently cited barrier (n=93 vs. n=73) for the Neurogenic Bowel recommendations. Lack of ability was further refined to patient factors (e.g., “lack of cognition,” “family lives too far away to participate in education”); unit factors (e.g., “no clear format for documenting bowel care”) and hospital factors (“nursing skill levels are inadequate to do appropriate assessment”).
Conclusions: Providers tended to focus on system barriers, including lack of availability of supplies and/or pharmaceuticals. Based on this feedback, a Guideline Implementation Model, which includes templates for documentation, social marketing, and patient-mediated interventions was developed and is being implemented at six VA SCI Centers.
Impact statement: These focus groups were extremely helpful in identifying providers' perceptions about obstacles and facilitators. Data on the effectiveness of various implementation efforts on patient specific outcomes is still being collected.