Behaviour Change for Best Practice

1
Behaviour Change for Best Practice

• Implementation of Clinical Practice Guidelines
• Peter Dodek, MD, MHSc
• University of British Columbia

2
Nutrition and Practice Guidelines

• Medline search1966-2003
• 232 articles about practice guidelines
• 253 articles that are practice guidelines

3
Outline

• Theories of behaviour change
• Effective and ineffective implementation
  strategies
• A real-life example

4
Social and Behavioural Theories

• Diffusion of Innovations
• Early and late adopters
• Readiness to change
• Pre-contemplation, contemplation, preparation,
  action, maintenance
• Health Education
• Educational needs, active strategies
• Social Influence
• Opinion leaders, academic detailing, group
  workshops
• Social Ecology
• Environment clinical reminders, teachable
  moment

5
Characteristics of Innovations

• Perceived relative advantage
• Compatibility--with existing values, past
  experiences, and needs of potential adopters
• Complexityto understand and use
• Trialability
• Observabilityof results

Rogers EM. Diffusion of Innovations (4th ed) Free
Press, 1995.
6
(No Transcript)
7
The Innovation-Decision Process

• Knowledge
• Persuasion
• Decision
• Implementation
• Confirmation

Rogers EM. Diffusion of Innovations (4th ed.)
Free Press, 1995.
8
Push, pull, capacity model

• Push rigorous guideline development
• Pull create demand for guidelines
• Endorsement by professional organizations,
  linkage between guideline outcomes and quality
  measures
• Capacity systems to facilitate implementation
• Audit/feedback, benchmarking, benefit coverage

Curry SJ. Chest 2000 118 40S-46S.
9
A Conceptual Framework for Implementation of
Guidelines

• Assess practitioners readiness for change
• Eg. Survey of practice, needs, willingness
• Assess barriers to guidelines use--survey
• Determine level of intervention
• Individual/group or population
• Design dissemination/implementation strategies
• Multiple focus on knowledge, attitudes, and
  skills
• Evaluate effectiveness of implementation
  strategies

Moulding NT et al. Qual Health Care. 1999 8
177-183.
10
Effective Implementation Strategies

• Educational outreach academic detailing
• Opinion leaders
• Patient-mediated interventions
• Reminders (especially computer-generated)
• Audit and feedback
• Multi-faceted

Grimshaw JM et al. Med Care. 2001 39 (supp 2)
II2-II45.
11
Less Effective Implementation Strategies

• Passive dissemination alone
• Traditional didactic approaches
• Peer comparison/physician profiling
• Case management
• Retrospective feedback

Weingarten S. Chest 2000 118 4S-7S.
12
Practice Guideline for Blood Gas Measurement in
the ICU

• Tension for Change
• Participation
• Constancy of Purpose
• Process Improvement
• Implementation Strategies
• Evaluation
• Dissemination of Results

13
Tension for Change

• Critical Care services 10-15 of health care
  costs
• Arterial blood gas measurement most common test
  in the ICU
• Clinical uncertainty about indications

14
Participation

• Who are the key stakeholders?
• Physicians, nurses, respiratory therapists,
  laboratory physicians, clinical epidemiologist
• Internal and external reviewers

15
Constancy of Purpose--Aim

• To assist physicians, nurses, and respiratory
  therapists who care for patients in the Intensive
  Care Unit setting in the decision to measure
  arterial blood gas tensions
• This guideline is an attempt to improve
  appropriateness and consistency of ordering this
  test

16
Process Improvement

• Describe current process
• List change concepts
• Re-design process
• External review
• New algorithm

17
(No Transcript)
18
Implementation Strategies

• Multi-pronged
• Pocket cards at bedside
• Seminars
• Decision support
• Audit and feedback

19
Evaluation

• Numbers of tests done
• Appropriateness of tests (compliance with
  guideline)
• Clinical outcomes ventilator days, length of
  stay, ICU mortality
• Costs

20
Practice Guideline is associated with Fewer Tests
21
Practice Guideline is associated with more
Appropriate Tests
22
Practice Guideline is associated with Savings
23
Sharing Results

• Poster presentations
• Hospital newsletter
• Publication Critical Care Medicine. 1997
  251308-1313

24
Summary

• Start with a rigorously developed guideline
• Consider needs of the intended users
• Choose multiple effective strategies
• Evaluate