Factors affecting adherence to a quality improvement checklist on an inpatient hepatology service
Elliot B Tapper1, Michelle Lai1
1Division of Gastroenterology (Tapper, Lai) and Department of Medicine (Tapper), Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Insights
Improving adherence to practice guidelines in hepatology requires addressing physician commitment and task-related barriers. A multimodal intervention significantly increased checklist adherence from 46% to 83%.
Area of Science:
- Hepatology
- Medical Quality Improvement
- Clinical Practice Guidelines
Background:
- Increasing emphasis on quality indicators necessitates measuring adherence to practice guidelines.
- Barriers to guideline adherence in academic inpatient hepatology services require identification and mitigation.
Purpose of the Study:
- To determine factors and barriers affecting guideline adherence in an academic inpatient hepatology service.
- To implement and assess the impact of a multimodal intervention to improve adherence.
Main Methods:
- A single-center, prospective observational study was conducted.
- Physicians used a daily handheld checklist to track adherence.
- Surveys identified reasons for nonadherence, which were then addressed through a multimodal approach.
Main Results:
- Baseline checklist adherence was 46%.
- Key barriers included attending physician prompting, checklist availability, and physician forgetfulness.
- Following a multimodal intervention, adherence increased significantly to 83% (P < 0.001).
Conclusions:
- Addressing specific barriers related to physician commitment and task execution is crucial for improving guideline adherence.
- A multimodal intervention can effectively enhance adherence rates in clinical practice.
- Sustaining checklist adherence requires ongoing commitment from the entire medical team.
Abstract:
Given the increasing emphasis on measuring quality indicators such as adherence to practice guidelines, we sought to determine the factors and address the barriers affecting guideline adherence on an academic inpatient hepatology service. We performed a single-center, prospective observational study. Physicians were given a handheld checklist to complete daily. We first measured the adherence rate and studied factors affecting adherence by performing surveys. We then modified the program to address the factors affecting adherence and reassessed the adherence rate. There was a baseline 46% checklist adherence rate. Reasons given for nonadherence fell into two categories: ease of task and physician commitment from both attending physicians and housestaff. Specific reasons given were that the attending did not prompt (39%), the adherence sheet was not in the chart (35%), the individual forgot (12%), as well as lack of time, unclear protocol, "too difficult," and "didn-t pay attention" (4% each). Each of these factors was addressed with a multimodal approach. Thereafter, the adherence rate rose from 46% to 83% (P < 0.001). Maintaining checklist adherence is time intensive and requires commitment from the whole medical team.
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