Session number: 1114
Abstract title: Barriers and Facilitators of Clinical Practice Guideline (CPG) Implementation
Author(s):
JA Pugh - VERDICT, South Texas Veterans Health Care System
R Best - VERDICT, South Texas Veterans Health Care System
F Moore - U Texas HSC at Houston, School of Public Health
S Hysong - University of Houston
B Sugarman - VERDICT, South Texas Veterans Health Care System
S Hull - Wellspring
W Spears - U Texas HSC at Houston, School of Public Health
Objectives: The VHA endorses the use of CPGs to improve quality of care. By creating performance measures based on CPGs, facilities are pushed to improve compliance. Our objective is to describe barriers and facilitators to CPG implementation experienced by VHA facilities.
Methods: Four VISNs were selected based on External Peer Review Program performance scores (3 high performers, 1 low performer) as well as the stated VISN strategy for implementing CPGs.Within each VISN 4 facilities were chosen based on their performance scores: 1 high, 1 low and 2 improvers over a 2-year period. Semi-structured qualitative interviews were conducted on site (both main facility and one free-standing outpatient clinic) with leadership, quality management, and primary care personnel. Interviews were held with 2-3 individuals at a time gathering descriptions of CPG implementation efforts as well as barriers and facilitators to those efforts. Atlas.ti, a qualitative analysis software, was used to organize and store codes and associated passages from the interviews.
Results: Numerous barriers to CPG implementation are sited: time constraints (pressure to increase unique numbers of patients in the system, leading to increased panel size and decreased length of visit); competing priorities (too many CPGs in addition to waits and delays, patient satisfaction, implementation of CPRS, JCAHO preparation, etc.); focus on numbers not quality; insufficient technology capacity (inadequate staff capable of writing reminders and generating feedback reports); lack of attention and buy-in from leadership (often reflected by lack of dedicated resources); and, lack of flexibility in staffing. Facilitators and strategies include: distributing the tasks involved in satisfying a particular CPG across the members of the clinic team; availability of data to be used both for feedback and for targeting specific patients; focus on “doing the right thing” for the patients (including CPG concordant care);and, using technology (clinical reminders, CPRS) as a helpful but not sole strategy.
Conclusions: VHA personnel have acquired enormous experience in CPG implementation. Teamwork and focus on doing the right thing are facilitators while competing priorities and time and resource constraints are barriers.
Impact statement: As primary care services are expanded and revamped by the VHA, significant improvements in quality of outpatient care may be achievable through careful attention to minimizing barriers and promoting facilitators already identified by VHA personnel.