Background
Methods
Measurement of clinical practice guideline adherence
Site selection
Participants
Facility
|
Hierarchical Level
|
Total # of Participants
|
Total # of Interviews
| |||
---|---|---|---|---|---|---|
Primary Care Personnel | Middle/Support Management | Facility Leadership | ||||
High Performers | 1 | 14 | 2 | 3 | 19 | 8 |
2 | 6 | 10 | 7 | 23 | 14 | |
3 | 7 | 4 | 3 | 14 | 9 | |
Low Performers | 4 | 4 | 8 | 4 | 16 | 8 |
5 | 3 | 4 | 4 | 11 | 7 | |
6 | 7 | 10 | 2 | 19 | 8 | |
Total | 41 | 38 | 23 | 102 | 54 |
Procedure
Data analysis
Open coding
Axial coding
Selective coding
Results
Feedback characteristic patterns in high and low performing facilities
High Performers | Low Performers | |||||
---|---|---|---|---|---|---|
PROPERTY
| 1 | 2 | 3 | 4 | 5 | 6 |
Timely | E | E | E | E | C | C |
Individualized | E | E | C | N | N | N |
Non-Punitive | E | E | I | I | N | I |
Customizable | I | I | I | N | N | I |
Timeliness
Individualization
Punitiveness
Customizability
A model of actionable feedback
Discussion
Limitations
Conclusion and future directions
Appendix: Interview guide and protocol notes
Notes on interview protocol
CONCEPT TAPPED | PRIMARY QUESTION | POSSIBLE PROBES |
---|---|---|
Quality of Care in General
| 1. How do you or your staff identify quality of care issues in need of improvement for your OUTPATIENT primary care clinics? |
Probe for explicit processes (e.g., strategic planning, balanced score cards, data that is monitored, etc.)
|
a. Who would be responsible for initiating and carrying out such efforts? | ||
b. Who would be responsible for monitoring such efforts? | ||
Mental Models of Clinical Practice Guidelines (CPG)
| 2. What does the term "Clinical Practice Guidelines" mean to you? | a. What role do you see for clinical practice guideline use as a method for improving quality of care? |
b. Do you believe clinical practice guidelines are effective for improving quality of care? Please explain. | ||
If no, follow up with, "Despite your beliefs, what is your experience? | ||
3. How do guidelines help you improve the quality of care you provide your patients? | a. As a source of data feedback? | |
b. How is data collected and utilized in your facility to improve the quality of patient care (e.g., administrative "scorekeeping" or as feedback for improving the quality of care)? | ||
c. Was EPRP data or other data on performance distributed? | ||
d. Did EPRP results affect individual performance evaluations? | ||
e. Does the facility collect clinical outcome data (mortality, readmission, functional status) related to the guideline? | ||
CPG Success Story
| 4. Could you tell us the story of a time you and your team successfully implemented a clinical practice guideline (e.g., smoking cessation, depression screening, diabetes mellitus, hypertension, etc.)? |
Probe for the Who, What, When, Where, & How of the story. |
a. What were the steps? | ||
b. Who was involved? To what extent are clinicians involved in determining how to implement guidelines? | ||
c. How was this guideline effort brought to the attention of clinicians and managers in your facility? (e.g., formal meetings, guideline champions, grand rounds, e-mail distributions, web sites, etc)? | ||
d. To what extent were committees (one steering committee for all guidelines or guideline specific committees) used to implement guidelines? | ||
e. What made it a success? | ||
CPG Training Development
| 5. Please describe the training (i.e., professional development) that clinicians have received for implementing guidelines. | a. Would clinicians say they have been provided adequate support for professional development with respect to CPG implementation? |
b. Any training in the use of technology (e.g., CPRS, clinical reminders, etc.)? | ||
c. CME credit? | ||
Facilitators
| 6. What are the most important factors that facilitate guideline implementation? | a. Technology (CPRS, clinical reminders)? |
b. Targeted educational or training programs, patient specific reminder systems, workshops, retreats? | ||
c. Incentives (e.g., monetary, extra time off from work, gift certificates, etc.)? | ||
d. Mentoring or coaching? | ||
e. Additional resources (e.g., equipment, staff, etc.)? | ||
f. Social Factors such as teamwork or networks? | ||
g. Representation from a diversity of service lines? | ||
h. Presence of a guideline champion? | ||
i. Supportive leadership (i.e., VISN and/or facility)? | ||
j. Pocket cards or "lite" versions of the guidelines? | ||
Barriers
| 7. What are the most important factors that hinder guideline implementation? | a. Lack of resources or staff? |
b. Time (i.e., patient interactions are targeted for 20 minutes)? | ||
c. Lack of training? | ||
d. Not enough support? | ||
e. Financial? | ||
Innovations
| 8. Were there any changes or redesigns in the clinical practices or equipment that supported the use of CPGs. | a. How were forms/procedures or reports changed to support adherence to guidelines? |
b. How were the responsibilities of nurses, aides, other personnel changed to support adherence? | ||
c. How were resources allocated/reallocated to support adherence? | ||
Structural, logistic, and organizational factors
| 9. Please describe any other conditions that may influence CPG implementation? | a. Size of the facility? |
b. Academic affiliation? | ||
c. Competition with other QI initiatives? | ||
d. Location (e.g., remote vs. main facility)? |