Overcoming Barriers to Guideline Implementation
Claudia D. Spies, MD
Charite Universitatmedizin Berlin
Berlin, Germany
Goetz Bosse, MD
Charite Universitatmedizin Berlin
Berlin, Germany
Jan-Phillip Breuer, MD
Charite Universitatmedizin Berlin
Berlin, Germany
Torsten Schröder, MD
Roland Kersten, MD
References
Quality of care is seen as the key variable most likely to increase desired outcome.1 With the increasing emphasis on patient safety in the last decades, providing quality care and improving the care process are of utmost importance in the attempt to ensure patient satisfaction and desirable outcomes.
An instrument is required to bridge the differences between scientific evidence and practical application.2 In critical care, guidelines and protocols have contributed greatly to improved processes and increased quality of care.3 Despite this, at least 30% to 40% of patients do not receive care according to the current scientific evidence, while 20% or more of care is not needed or is potentially harmful to the patient.4 Several authors have shown that protocols and guidelines can improve both process quality and the outcome of care.5,6 In 55 of 59 guideline studies, Grimshaw et al verified at least one beneficial change in the process of care.5 High compliance with evidence-based standard operating procedures is known to reduce the length of stay and total hospital costs. As previously reported, non adherence to the sepsis bundles increased mortality rates in septic patients.7
Although scientific data are available, resistance to adopting proven practices is still widespread.8 The reasons for this resistance remain unclear. Significant barriers exist between the introduction of best medical practice and its implementation into the daily routine. In a review of 76 studies, Cabana et al analyzed markers that impede guideline adherence.9 Crucial factors that hinder implementation include:
• Lack of awareness that a guideline exists
• Lack of familiarity and agreement
• Lack of motivation
• Low expectations for favorable outcomes
• Perceived external barriers beyond the control of individuals
The need to demonstrate the effectiveness of quality measures on patient safety “represents a shift in culture from basing decisions on opinion, past experiences and precedents toward more utilization of science, research and evidence to guide clinical decision making,” according to the National Association of Health Authorities and Trusts, London. 10 This culture shift will be the challenge of the coming years as the healthcare community strives to ensure that effective therapies and diagnostic skills are provided. “The most cost-effective opportunity to improve the quality of care will not come from discovering new therapies, but from discovering how to deliver therapies that are known to be effective.”
To achieve this objective, we need to seek information about good evidence, communicate this evidence to the entire team, apply it appropriately and monitor its application and outcomes. Psychological learning theories provide insight into the reason for noncompliance and may offer possible solutions. Different barriers need different intervention strategies, and many authors have described various methods to address the problem of resistance to culture and process change. Grol et al11 provided an overview of the diverse methods and approaches, including:
• Educational strategies, audits and feedback
• Multidisciplinary and multiprofessional collaboration
• Total quality management
• Financial- and patient-mediated interventions
All of these are effective in addressing parts of the issue of process change, but no method can claim to be the perfect solution to all problems. To meet the challenges and overcome the barriers to change, we need to understand the complexity of this multidimensional problem and the unique contributing factors. Methods, tools and interventions should be adjusted and combined to meet the patient’s needs.12
Why Simulation Training is Effective
An approach based on simulation training can integrate this type of multifaceted strategy. Simulators allow healthcare professionals to use technical and non-technical skills to overcome the barriers to guideline implementation and ease the shift in process and culture change. This hands-on training is available in more than 1,000 simulation centers worldwide and has proved a valuable tool for crisis resource management courses such as the Society of Critical Care Medicine’s Fundamental Critical Care Support program. Simulation is an educational tool founded on a problem-based learning approach. It integrates peer-group review and internal auditing. It focuses on the needs of the participants, so the exercise can be tailored more effectively to achieve the desired outcomes.
To evaluate the application of simulation training as a means to implement guidelines, a pilot study on the implementation of the sepsis bundles was conducted. and presented at the SCCM in Orlando this year. This study compared the effectiveness of a slide presentation, which previously was the tool used most often, with intensive care unit (ICU) simulation training. Participants were interviewed after the training session, and it was clear that simulation training was preferred to the slide presentation. Most participants said they gained a better understanding of leadership, communication and teamwork with the simulation training because it reached a deeper psychological level. These concepts seem to be crucial in creating an environment where process change and guideline implementation are received positively.
Guideline implementation is as complex as the reasons that hinder it. It often is hard to change the culture and processes of an ICU team. Only a combination of approaches can help a team understand the reasons for the barriers to change and help it overcome these challenges. Simulation training offers a hands-on experience and a deeper understanding of such intangible concepts such as teamwork and communication. Finding effective means of overcoming barriers related to guideline implementation is important because, ultimately, it will result in improved patient safety and care.
