AHRQ Safety Program for Surgery
Guidelines summarizing evidence exist to help ensure that patients receive recommended interventions. In addition, consistent guideline adherence may significantly improve patient safety. However, adherence to these evidence-based guidelines remains highly variable both within and between units, hospitals, and States. Tools to identify factors that hinder guideline adherence, also called barriers, and approaches to mitigating these barriers within individual clinical units are also lacking. Barriers to achieving consistent adherence to evidence-based guidelines are commonly related to provider, guideline, and system characteristics.
Purpose of This Tool
Since particular barriers and the corresponding solutions may differ between individual clinical units, the Barrier Identification and Mitigation (BIM) Tool was designed to help frontline staffs systematically identify and prioritize barriers to guideline or intervention adherence within their own care setting. This tool also provides a framework for developing an action plan targeted at eliminating or mitigating the effects of the identified barriers. Providing a practical and interdisciplinary approach to these barriers, the BIM tool aids safety program efforts.
Who Should Use This Tool?
Both frontline clinicians (e.g., physicians and nurses) and nonclinicians (e.g., unit administrator, unit support staff, hospital quality officer) within a care setting may use this tool. Often a subcommittee of the safety program team is assigned to assess barriers. All safety program team members should understand the Comprehensive Unit-based Safety Program (CUSP) and be familiar with the Science of Safety video.
How To Use This Tool
The BIM tool is best applied within the context of a comprehensive quality and safety improvement effort. This tool should be used periodically (every 3 to 6 months) to identify barriers if adherence to a guideline or therapy is poor. This document summarizes the five-step process and provides more detailed explanations and sample forms for each step. You can use the AHRQ Safety Program for Surgery Toolkit to guide your team through the quality improvement intervention design process.
Summary of BIM Tool Process
Compose a diverse subgroup from the safety program team. Use the BIM Team Information Form to gather contact information for subgroup members.
Subgroup members can work independently to identify and record barriers to guideline adherence. They will observe and ask questions about the process, as well as walk through a simulation or, if appropriate, real clinical practice. Use the Barrier Identification Table to provide a framework to identify and record barriers, contributing factors to barriers, and potential actions to ameliorate those barriers.
After collecting data, compile the barrier data recorded by the several investigators. Then summarize this information and record any suggestions provided by observers to improve adherence. Use the Barrier Summary and Prioritization Table to summarize barriers, include each barrier’s relation to the guideline, identify method of data collection, and rate each barrier with a likelihood, severity, and priority score.
The subgroup can then review and discuss the barrier summary. Next, rate each barrier on the likelihood of the barrier occurring within the unit and the severity of the barrier’s impact on guideline adherence. Multiply the likelihood and severity scores together to calculate a ranked priority score.
Review suggested actions to eliminate or mitigate the selected high-priority barriers. As a team, select individual actions for the next improvement cycle based on the potential impact and feasibility of improvement with available resources. Based on these two factors, an action priority score is calculated, providing a ranked list of tasks. Use the Action Plan Development Table to compile high-priority barriers, potential actions to eliminate or mitigate barriers, and evaluation measures to assess those actions. It also provides a mechanism to rank potential actions based on expected impact, feasibility, and priority.
Step 1: Assemble Interdisciplinary Team
First, compose a diverse team to examine a specific quality problem. This BIM team should be a subcommittee of the surgical safety program team. Make sure the team is interdisciplinary and includes members with varying levels of experience and training. The team will characterize local barriers, develop an action plan to overcome these difficulties, and achieve consistent compliance with guidelines.
Encourage clinical staff (e.g., physicians, nurses), support staff (e.g., unit administrators, technicians), and content experts (e.g. hospital quality officers) to join this effort. Additionally, all BIM team members should be trained on the science of patient safety (e.g., having viewed the Science of Safety video) and be familiar with the overall process for improving quality. Refer to the AHRQ Safety Program for Surgery guide to Applying the Comprehensive Unit-based Safety Program (CUSP) to Promote Safe Surgery for additional information.
List the team member names and responsibilities on the BIM Team Information Form.
BIM Team Information Form
Compose a diverse subgroup from the safety program team. Use the BIM Team Information Form below to gather contact information for subgroup members.
|NAME AND TITLE
|Medical director of unit
|Nurse practitioner/nurse specialist
|Nurse manager for unit
|Nonclinical administrator for unit
|Quality improvement specialist
|Human factors engineer
|Technician for unit
|Other unit support staff member
|Other content expert
Step 2: Identify Barriers
Several team members should work independently to identify barriers to consistent guideline adherence in the targeted clinical area. Utilizing different modes of data collection facilitates obtaining an accurate and complete picture of the factors influencing guideline adherence.
- Observe a few clinicians engaged in the tasks related to the guideline.
- As an observer, cause as little distraction as possible.
- Focus on observing rather than documenting during this period. Jotting a few notes is OK, but wait to complete the Barrier Identification Form until immediately following the observation period.
- Along with the barriers to achieving consistent adherence to the guideline, indicate any skipped steps or workarounds, such as improvised process steps or factors that facilitated compliance with guideline.
- Ask various staff members about the factors influencing compliance.
- Include informal discussions, interviews, focus groups, and brief surveys.
- Assure staff that their responses will be confidential.
- Ask staff about the problems they face and any ideas they have regarding potential solutions for improving compliance to guidelines.
- Are staff aware that the guideline exists?
- Do staff believe that the guideline is appropriate for their patients?
- Do staff have any suggestions to improve compliance?
Walk the Process
- Follow the practice either as a simulation, or if appropriate, during real clinical practice.
- Continue collecting data until no new barriers are identified and a comprehensive understanding of good practices and barriers to guideline adherence is achieved. This process can take approximately 3 to 6 hours.
The investigators record all potential reasons that clinicians experienced difficulties with complying with the guideline in the Barrier Identification Table; these are the barriers. They will also record the factors that encourage compliance; these are the facilitators. Indicate the method of data collection (e.g., observation, survey, focus group, informal discussion, interview, or walking the process), the data collector, and the clinical unit.
Barrier Identification Table
|DATA COLLECTION MODE:
|Knowledge of the guideline
What are the elements of the guideline?
|Attitude regarding the guideline
What do you think about the guideline?
|Current practice habits
What do you currently do (or not do)?
|Perceived guideline compliance
How often do you do everything right?
|Evidence supporting the guideline
How "good" is the supporting evidence?
|Applicability to unit patients
Does the guideline apply to the unit's patients?
|Ease of complying with guideline
How does compliance affect the workload?
Who is responsible for following the guideline?
|Tools and technologies
What supplies and equipment are available/used?
How often are aids available and used?
How does the unit layout affect compliance?
How does the organizational structure (e.g., staffing) affect compliance?
How does the administration affect compliance?
How does the unit know it is following the guideline?
How does the unit culture affect compliance?
Step 3: Compile and Summarize Barrier Data
Once data collection is complete, compile the data from the various investigators with the Barrier Identification Table. Summarize the information in columns 1, 2, and 3 of the Barrier Summary and Prioritization Table:
- In column 1, briefly summarize each barrier.
- In column 2, provide a brief description of the part of the guideline to which the particular barrier pertains.
- In column 3, provide the source of data collection, such as—
- Informal discussion.
- Focus group.
- Walking the process.
Step 4: Review and Prioritize Barriers
As a team, review and discuss the barrier summary. Then, in columns 4, 5, and 6 of the Barrier Summary and Prioritization Table, rate each barrier on the likelihood of the barrier occurring in the unit (likelihood score) and the probability that it would lead to guideline nonadherence (severity score). Each barrier is scored from 1, indicating a low likelihood or severity, to 4, indicating a high likelihood or severity. The priority score for each barrier is then calculated by multiplying the likelihood and severity scores.
The higher the priority score for a barrier, the more critical it is to eliminate or mitigate the effects of that barrier. As a team, develop your own criteria for determining which barriers to target during this quality improvement cycle. For instance, you could set a priority score threshold to decide which barriers to target (e.g., barriers with a priority score ≥ 9) or target the top three barriers.
How likely is it that a clinician will experience this barrier?
1. Low 2. Moderate 3. High 4. Very high
How likely is it that experiencing this particular barrier will lead to nonadherence with the guideline?
1. Low 2. Moderate 3. High 4. Very high
Barrier Priority Score
Multiply the likelihood score by the severity score to calculate the barrier priority score.
Barrier Summary and Prioritization Table
Step 3 and 4: Compile, summarize, review as a team, and prioritize the barrier data collected from the investigators.
|RELATION TO GUIDELINE
|BARRIER PRIORITY SCORE
|TARGET FOR THIS CYCLE
Step 5: Develop an Action Plan for Barriers
As a team, list and review the potential actions to eliminate/mitigate the selected high priority barriers in the Action Plan Development Table–as suggested by the observers in Step 2. Next, brainstorm additional potential actions and record in the Action Plan Development Table.
Select specific actions as a team to address in the next improvement cycle based on the potential impact to compliance and the feasibility with current resources. Rate each action with a potential impact score and a feasibility score. As in Step 4, each action is scored from 1, indicating a low impact or feasibility, to 4, indicating a high impact or feasibility. The action priority score is calculated as follows: multiply the potential impact score by the feasibility score. Your team can prioritize the actions and schedule as appropriate for your clinical setting.
Examine the feasibility of implementing an action. For example, installing a sink in each patient's room may increase the frequency of clinicians washing their hands, but installing a hand sanitizer dispenser is more cost effective. For each action, the group should assign an appropriate leader, performance measures, and followup dates to evaluate progress. Record this information in the Action Plan Development Table.
Potential Impact Score
What is the potential impact of the intervention on improving guideline adherence?
1. Low 2. Moderate 3. High 4. Very high
How feasible is it to take the suggested action?
1. Low 2. Moderate 3. High 4. Very high
Action Priority Score
Multiply the potential impact score by the feasibility score to calculate the action priority score.
Action Plan Development Table
|POTENTIAL IMPACT SCORE
|ACTION PRIORITY SCORE
|PERFORMANCE MEASURE METHOD
|FOLLOW UP DATE