Search

Background: The implementation of evidence-based practices translates research findings into practice to reduce inappropriate care. However, this process is slow and unpredictable. The lack of a coherent theoretical basis for understanding individual and organizational behavior limits our ability to formulate effective implementation strategies., Purpose: The study objectives are (a) to test the goal commitment framework that explains mechanisms impacting outcomes of major depressive disorder (MDD) screening guideline implementation and (b) to understand the effects of implementation outcomes on provider practice related to MDD screening., Methods: Using data from the Determinants of Clinical Practice Guideline Implementation Effectiveness Study, the national sample included 2,438 clinicians from 139 Veteran Affairs acute care hospitals with primary care clinics. We used hierarchical generalized linear modeling to assess the following implementation outcomes: agreement with, adherence to, improvement in knowledge of guidelines, and delivery of best practices as a function of clinician input into implementation, teamwork, involvement in quality improvement activities, participative culture, interdepartmental coordination, frequency, and utility of performance feedback. We then estimated self-reported MDD screening practices as a function of these four implementation outcomes., Findings: Results showed that having input into implementation, involvement in quality of care improvement, teamwork, and perceived value of performance feedback were positively associated with implementation outcomes. Provider self-assessed guideline adherence was positively associated with the likelihood of appropriate MDD screening., Implications: Factors related to increased goal commitment positively predicted key implementation outcomes, which in turn enhanced care delivery. This study demonstrates that the goal commitment framework is useful in assisting managers to assess factors that facilitate implementation. In particular, participation, feedback, and team work equip organizational participants with better information about implementation targets, thereby increasing adherence. Instituting or improving systems or programs to facilitate timely, appropriate performance feedback and provider participation may help enhancing organizational change and learning.

Background: Gaps between evidence and practice in the care of patients with chronic heart failure (CHF) in the United States suggest major opportunities for improvement. However, the organizational factors and implementation approaches that influence adherence to national guidelines are poorly understood., Objectives: The objectives of this study were to explore the degree to which providers in the Veterans Health Administration system adhere to CHF clinical practice guidelines, and to identify facility-level factors influencing adherence., Design: In a national cross-sectional study, facility quality managers were surveyed regarding quality improvement efforts, guideline implementation, and context. These data were linked to organizational structure data and provider adherence data from chart reviews. The unit of analysis was the facility. The data were adjusted for the average number of comorbidities per CHF patient. Multivariate logistic regression models were constructed to model factors affecting adherence to CHF guidelines., Sample: The sample consisted of 143 Veterans Administration Medical Centers with ambulatory care clinics., Results: The quality manager survey included data from 91% of facilities. Facility-level estimates of provider adherence measures were, on average, 85% or more for most measures. In multivariate analyses, facilities with higher levels of adherence were more likely to have: (1) providers who had been given a brief guideline summary, (2) providers receptive to the guidelines, (3) guideline-specific task forces to support implementation, and 4) a well-planned implementation process., Conclusions: Healthcare organizations should adapt implementation to meet local conditions, including creating guideline-specific task forces, developing a well-planned implementation process, fostering provider buy-in, and providing guideline summaries to providers.

Rationale, Aims and Objectives: A clinical practice guideline for chronic obstructive pulmonary disease (COPD) was implemented in all Veterans Health Administration (VHA) hospitals in the US. The aim of the current analyses is to describe current adherence rates and the organizational factors related to provider adherence to the COPD guideline., Methods: We administered a survey to key informants that assessed adherence to the COPD guideline, approaches to disseminating and implementing the COPD guideline, providers' views of the COPD guideline and guidelines in general, and attitudes about the organizational climate., Results: Surveys were returned by 242 key informants (58%) at 130 of the 143 VHA hospitals (91%). Adherence to the COPD clinical practice guideline is perceived by quality managers within the VHA to be good. The final multivariable predictor model identified five measures that were related to provider adherence with the COPD guideline (R(2) = 0.43): responsibilities were changed to support adherence to the COPD guideline, physicians believe that guidelines implemented in the past year were applicable to their practice, patient care providers consistently participate in activities to improve the quality of care, the regional network office monitors the pace at which guidelines are implemented, and there is a system to provide feedback on routinely collected guideline adherence data collected in addition to External Peer Review Program data., Conclusions: Organizations can play an important role in providing a supportive climate to facilitate their providers' adherence to guidelines by implementing processes and culture changes that involve these five measures.

Hospitals use numerous guideline implementation approaches with varying success. Approaches have been classified as consistently, variably, or minimally effective, with multiple approaches being most effective. This project assesses the Department of Veterans Affairs (VA) use of effective guideline implementation approaches. A survey of 123 VA quality managers assessed the approaches used to implement the chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, and major depressive disorder guidelines. Approaches were categorized based on their effectiveness, and the total number of approaches used was calculated. Commonly used approaches were clinical meetings, summaries, and revised forms. Consistently and minimally effective approaches were used most frequently. Most hospitals used 4-7 approaches. Odds ratios demonstrated that consistently effective approaches were paired with minimally and variably effective approaches. The frequent use of consistently effective approaches and multiple approaches benefits VA adherence. However, VA hospitals should consider selective combinations of approaches to ensure the use of the most effective implementation methods.

Background: Optimal diabetes management relies on providers adhering to evidence-based practice guidelines in the processes of care delivery and patients adhering to self-management recommendations to maximize patient outcomes., Purpose: To explore: (1) the degree to which providers adhere to the guidelines; (2) the extent of glycemic, lipid, and blood pressure control in patients with diabetes; and (3) the roles of organizational and patient population characteristics in affecting both provider adherence and patient outcome measures for diabetes., Design: Secondary data analysis of provider adherence and patient outcome measures from chart reviews, along with surveys of facility quality managers., Sample: We sampled 109 Veterans Affairs medical centers (VAMCs)., Results: Analyses indicated that provider adherence to diabetes guidelines (ie, hemoglobin A1c, foot, eye, renal, and lipid screens) and patient outcome measures (ie, glycemic, lipid, and hypertension control plus nonsmoking status) are comparable or better in VAMCs than reported elsewhere. VAMCs with higher levels of provider adherence to diabetes guidelines had distinguishing organizational characteristics, including more frequent feedback on diabetes quality of care, designation of a guideline champion, timely implementation of quality-of-care changes, and greater acceptance of guideline applicability. VAMCs with better patient outcome measures for diabetes had more effective communication between physicians and nurses, used educational programs and Grand Rounds presentations to implement the diabetes guidelines, and had an overall patient population that was older and with a smaller percentage of black patients., Conclusions: Healthcare organizations can adopt many of the identified organizational characteristics to enhance the delivery of care in their settings.

Objective: To examine organizational factors and occupational characteristics associated with adherence to occupational safety guidelines recommending never recapping needles., Design: Mail surveys were conducted with healthcare workers (HCWs) and infection control professionals (ICPs)., Setting: The surveys were conducted at all non-federal general hospitals in Iowa, except one tertiary-care hospital. Survey data were linked to annual survey data of the American Hospital Association (AHA)., Participants: HCWs were sampled from statewide rosters of physicians, nurses, and laboratory workers in Iowa. Eligible HCWs worked in a setting and position in which they were likely to routinely handle needles. ICPs at all hospitals in the state were surveyed., Results: Ninety-nine ICPs responded (79% response rate). AHA data were available for all variables from 84 (85%) of the hospitals. Analyses were based on 1,454 HCWs who identified one of these hospitals as their primary hospital (70% response rate). Analyses were conducted using multiple logistic regression. Positive predictors of consistent adherence included infection control personnel hours per full-time-equivalent employee (odds ratio [OR], 1.03), frequency of standard precautions education (OR, 1.11), facilities providing personal protective equipment (OR, 1.82), facilities using needleless intravenous systems (OR, 1.42), and management support for safety (OR, 1.05). Negative predictors were use of "blood and body fluid precautions" isolation category (OR, 0.74) and increased job demands (OR, 0.90)., Conclusion: Healthcare organizations can improve staff safety by investing wisely in educational programs regarding approaches to minimize these risks, providing protective equipment, and eliminating the use of blood and body fluid precautions as an isolation policy.

Provider knowledge is a potential barrier to adherence to clinical guidelines. The purpose of this study is to assess the impact of organizational, provider, and guideline factors on provider knowledge of a congestive heart failure (CHF) clinical practice guideline (CPG) in the Veterans Health Administration (VHA) health care system. We developed a survey to investigate institution-level factors influencing the effectiveness of guideline implementation, including characteristics of the guideline, providers, hospital culture and structure, and regional network. Survey participants were quality managers, primary care administrators, and other individuals involved in primary care CPG implementation at 143 VHA hospitals with ambulatory care clinics. Potential explanatory variables were grouped into 11 factors. Multivariate regression models assessed the association between these factors and reported levels of provider knowledge regarding the CHF guideline at the hospital level. Two hundred forty surveys from 126 of 143 (88%) VHA hospitals were returned. Provider knowledge of the CHF guideline was estimated as "great" or "very great" by 58% of respondents. Three predictor factors (dissemination approaches, use of technology in guideline implementation, and hospital culture) were independently associated (P < or = .05) with provider knowledge. Specific variables within these categories that were related to greater knowledge included physician belief that guidelines were applicable to their practice, distribution of guideline summaries, use of guideline storyboards in clinic areas, the use of technology (eg, electronic patient records) in CPG implementation, and establishment of implementation checkpoints and deadlines. Provider knowledge of guidelines is affected by factors at various organizational levels: dissemination approaches, use of technology, and hospital culture. Guideline implementation efforts that target multiple organizational levels may increase provider knowledge.

Background: The Agency for Health Care Policy and Research (AHCPR) smoking cessation guideline outlines a set of recommendations for physicians to follow in daily practice. However, the effectiveness of this guideline has not been reported. The goal of this project was to evaluate the effect of the AHCPR smoking cessation guideline on provider practices with smokers and on patient smoking rates., Methods: Patient survey and chart review data from 138 Veterans Administration (VA) acute care medical centers with outpatient facilities were examined. Data were available from both sources in 1996, 1997, and 1998. At the midpoint of this period (1997), the VA recommended the AHCPR smoking cessation clinical practice guideline for implementation throughout the VA healthcare system., Results: From 1996 to 1998, both the chart audit and the patient survey showed a significant increase in the percentage of patients in the VA who were counseled about smoking and a significant decrease in the percentage of patients who smoke., Conclusions: Because the VA tied the guideline implementation to report cards and other performance-enhancing measures, guideline adherence may have been maximized in this setting. These findings suggest that healthcare systems should take an integrated approach to guideline implementation.

Objective: The purpose of this study was to identify hospital organizational characteristics consistently associated with adherence to multiple clinical practice guidelines (CPGs). We examined the relationship between organizational and patient population characteristics and adherence to three screening CPGs implemented throughout the Veterans Health Administration (VHA)., Materials and Methods: The study included 114 acute care facilities. Three sources of data were used: 1998 American Hospital Association data, VHA External Peer Review Program data for 1998 and 1999, and the 1999 Veterans Satisfaction Survey. Organizational characteristics likely to affect adherence with the CPGs were classified into five conceptual domains (clinical emphasis, operational capacity, patient population, professionalism, and urbanicity). Organizational characteristics were ranked, based on their standardized beta coefficients in bivariate logistic regressions predicting the likelihood of adherence. Within-domain multivariable logistic analyses assessed the robustness of individual predictors of CPG adherence, controlling for other organizational factors within the same domain., Results: Overall, 46 of 48 relationships in the bivariate logistic analyses were significant, and 43 of these remained significant in the within-domain multivariate analyses. The relative rankings of the variables as predictors of CPG adherence within conceptual domains were also quite consistent., Conclusions: Strong evidence was found for the importance of specific organizational factors, including mission, capacity, professionalism, and patient population characteristics that influence CPG adherence in a large multi-institutional sample involving multiple provider practices. Research and programs to improve adherence to CPGs and other quality improvement activities in hospitals should incorporate these organizational factors.

Rationale, Aims and Objectives: Although clinical practice guidelines have been promoted widely, there is considerable concern that physicians have not incorporated them into their practice. Models suggest that a 'knowledge-attitude-behaviour' sequence is important in modifying physician practice patterns. To address this, we examined physicians' knowledge of, attitudes towards and compliance with a widely implemented guideline - the Agency for Health Care Policy and Research (AHCPR) smoking cessation guideline., Methods: A survey was mailed to a random sample of physicians at 128 veterans health administration facilities, which had implemented the guideline 2 years previously., Results: Completed surveys were received from 879 physicians (50.3 response rate). Only 26 of physicians reported receiving a copy or summary of the guideline, 44 reported little or no familiarity with it, 42 did not know if they agreed with it, 40 did not know if they complied with it and 46 did not know if it was effective. However, a high percentage of physicians reported that they always or usually explain the health risks of smoking (86) and that they always or usually suggest that their smoking patients stop (94)., Conclusions: In spite of little familiarity with the guideline, the responding physicians reported practice patterns consistent with adherence to it. Knowledge is only one of a spectrum of barriers that affects physician adherence to guidelines. There are numerous opportunities for health care organizations to overcome the barriers to physician adoption of clinical practice guidelines in their day-to-day practice.

We examined the relationship between physician adherence with a smoking cessation guideline and organizational structures, policies, leadership support, and physician knowledge and attitudes. A random sample of 844 physicians practicing in 127 VHA hospitals was surveyed. Survey results were aggregated to the hospital level and linked with data on organizational characteristics from the 1998 annual survey of hospitals by the American Hospital Association. Significant predictors of adherence included organizational policies related to nicotine replacement prescriptions, the timing and effectiveness of guideline implementation, physicians' knowledge of VHA clinical guidelines generally, and physicians' beliefs about the receptiveness of patients to smoking cessation.