Saint S (Ann Arbor VAMC and the University of Michigan), Kowalski CP
(Ann Arbor VAMC), Banaszak-Holl J
(The University of Michigan), Forman J
(Ann Arbor VAMC), Damschroder LJ
(Ann Arbor VAMC), Krein SL
(Ann Arbor VAMC and the University of Michigan)
Healthcare-associated infection (HAI) is a common patient safety problem. Starting in October 2008, U.S. hospitals will no longer receive Medicare reimbursement for certain types of HAI, thereby heightening the need for effective infection prevention efforts. The mere existence of evidence-based practices, however, does not equal the use of such practices because of the complexities inherent in translating evidence into practice. We sought to understand the barriers to implementing evidence-based practices to prevent HAI with a specific focus on the role played by hospital personnel.
We conducted a qualitative study involving phone and in-person interviews with personnel at 14 purposefully sampled hospitals from across the United States (seven hospitals were VAMCs). There were 86 participants including: chief executive officers, chiefs of staff, hospital epidemiologists, infection control professionals, intensive care unit directors, nurse managers, and front-line physicians and nurses. Each interview was transcribed and independent summaries were prepared for each site by four study team members who then met to question, discuss and document interpretations and findings.
Active resistance involving hospital personnel, who vigorously and openly opposed various changes in practice, increased the difficulty of implementing practice change and was pervasive. Successful efforts to overcome active resisters included benchmarking infection rates, identifying effective champions, and participating in collaborative efforts. Organizational constipators – mid- to high-level executives who act as insidious barriers to change – also increased the difficulty in implementing change. Recognizing the presence of constipators is often the first step in addressing the problem, but can be followed by including the constipator early in group discussions in order to improve communication and obtain buy-in or working around the individual.
We identified certain types of personnel that impeded HAI prevention activities. We also identified various approaches used by hospitals to overcome these barriers to change, such as providing benchmarked data, identifying and engaging local champions, and tackling the difficult situation of powerful constipators through early communication and engagement.
Our results can help VA hospital administrators and patient safety leaders design more successful strategies to prevent HAI in their hospitals and thus, decrease infection risk and improve veteran safety.