it’s not what you do; it’s how you do it!

www.ohri.ca | Affiliated with • Affilié à

IT’S NOT (JUST) WHAT YOU DO, IT’S (ALSO) HOW YOU DO IT!

JEREMY GRIMSHAW SENIOR SCIENTIST AND PROFESSOR KATHRYN SUH, MD, FRCPC

6TH OCT. 2016

[email protected] @GrimshawJeremy

mailto:[email protected]

WHO WE ARE Dr Kathryn Suh

▶ Medical Director, Infection Prevention and Control Program and Antimicrobial Stewardship Program, The Ottawa Hospital

▶ Associate Professor of Medicine, University of Ottawa.

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Dr Jeremy Grimshaw

▶ Senior Scientist, Ottawa Hospital Research Institute

▶ Professor of Medicine, University of Ottawa

Affiliated with • Affilié à

▶ Ensuring patient safety remains a high priority for healthcare systems, organisations and providers

▶ The Canadian Patient Safety Institute has been at the forefront of efforts to promote safety in Canadian Healthcare settings and has achieved substantial improvements in patient safety.

▶ However, there remain substantial challenges to implement patient safety practices.

▶ Shift to Safety, the newest program of CPSI is launching a new initiative to promote the use of behavioral approaches in patient safety initiatives.

BACKGROUND

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▶ Successful implementation of patient safety programs needs key actors (patients, healthcare providers, managers and policy makers) to change their behaviours and/or decisions whilst working in the complex (ordered chaos) of health care environments

▶ There is a substantial evidence base in behavioural sciences that can support the development of patient safety programs and increase the likelihood of success

BEHAVIOURAL PERSPECTIVE


▶ The Ottawa Centre for Implementation Research at the Ottawa Hospital Research Institute is an interdisciplinary group that undertakes research on behavioural approaches to enhance change programs

▶ We are partnering with CPSI to increase the Canadian capacity to use behavioral approaches to optimise change programs.

OTTAWA CENTRE FOR IMPLEMENTATION RESEARCH

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▶ Angel Arnaout, surgery, disinvestment in cancer

▶ Sylvain Boet, anesthesiologist, medical education

▶ Jamie Brehaut, cognitive psychologist

▶ Ian Graham, medical sociology

▶ David Moher, epidemiologist, knowledge syntheses

▶ Justin Presseau, health psychologist

▶ Janet Squires, nursing, implementation science

▶ Dawn Stacey, nursing shared decision making

▶ Monica Taljaard, biostatistician

▶ Kednapa Thavorn, health economist

▶ Noah Ivers, family physician, implementation science (Toronto)

▶ Holly Witteman, engineering, human factors (Quebec City)

OTTAWA CENTRE FOR IMPLEMENTATION RESEARCH

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DESIGNING CHANGE PROGRAMS

Who needs to do what differently?

Using a theoretical framework, which barriers and enablers need to be addressed?

Which intervention components could overcome the modifiable barriers and enhance the enablers?

How will we measure behaviour change?



▶ Specify behaviour using TACTA principle

▶ Identify: • What needs to be done (Action)

• By whom (Actor)

• To whom (Target)

• Where (Context)

• When (Time)


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▶ What needs to be done (Action) • Hand hygiene

▶ By whom (Actor) • All health care providers

▶ To whom (Target)

▶ Where (Context) • Clinical environments

▶ When (Time) • Four moments of hand hygiene


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DESIGNING IMPLEMENTATION PROGRAMS

THEORETICAL DOMAINS FRAMEWORK


Michie 2005 Knowledge

Skills

Social/professional role and identity

Beliefs about capabilities

Beliefs about consequences

Motivation and goals

Memory, attention and decision processes

Environmental context and resources

Social influences

Emotional regulation

Behavioural regulation

Nature of the behaviour

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Michie 2005 Knowledge

Skills

Social/professional role and identity

Beliefs about capabilities Beliefs about

consequences Motivation and goals

Memory, attention and decision processes

Environmental context and resources

Social influences Emotional regulation

Behavioural regulation Nature of the behaviour


Key beliefs:

▶ conflicting comments about who was responsible for the test-ordering (Social/professional role and identity);

▶ inability to cancel tests ordered by fellow physicians (Beliefs about capabilities and social influences);

▶ problem with tests being completed before the anesthesiologists see the patient (Beliefs about capabilities and Environmental context and resources).

▶ tests were ordered by an anesthesiologist based on who may be the attending anesthesiologist on the day of surgery while surgeons ordered tests they thought anesthesiologists may need (Social influences).


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▶ Graded tasks - Set easy tasks, and increase difficulty until target behavior is performed.

▶ Behavioural rehearsal/practice - Prompt the person to rehearse and repeat the behavior or preparatory behaviors


BEWARE POOR DESIGN


A PRACTICAL STUDY: PHYSICIAN HAND HYGIENE

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▶ Healthcare-associated infections are one of the top 10 causes of hospital deaths worldwide

• affect 10% of all patients in acute-care hospitals

▶ Physician hand hygiene compliance is an international problem

• Average reported compliance rate: 49-57%

▶ Reasons for poor compliance not well understood


A PRACTICAL STUDY: PHYSICIAN HAND HYGIENE

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ASSESSING BARRIERS AND ENABLERS

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▶ Key informant interviews with 42 staff physicians and residents in Medicine, Surgery

▶ Two focus groups with four institutional hand hygiene “experts”: hand hygiene auditors, infection prevention and control professionals, and Senior Management

▶ Observation of hand hygiene and audits on inpatient Medicine and Surgery units


▶ Knowledge: I am / am not aware of hand hygiene guidelines

▶ Skills: I have / have not had training in hand hygiene techniques

▶ Beliefs about consequences: hand hygiene reduces transmission of infection

▶ Memory and attention: reminders are / are not useful for hand hygiene

▶ Social influence: others on my team do / do not influence my hand hygiene behaviour

INTERVIEW GUIDE

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Knowledge Skills Social/professional role

and identity Beliefs about

capabilities Beliefs about

consequences Motivation and goals

THEORETICAL DOMAINS FRAMEWORK Memory, attention and

decision processes Environmental context

and resources Social influences Emotional regulation

Behavioural regulation

Nature of the behaviour


▶ Important TDF domains were prioritized with team input, and mapped to known effective behaviour change techniques

▶ Intervention focused on five prioritized domains, considering feasibility in our environment, and acceptability to the “actors”

• Knowledge; skills; beliefs about consequences; memory, attention and decision processes; social influences

▶ Intervention delivery differed for medicine and surgery

INTERVENTION MAPPING AND DESIGN


▶ Based on assessment of barriers, resources, practical aspects of implementation

▶ Medicine:

• Two slides for resident orientation

• Four x 2 minute sessions during stewardship rounds

• Glo GermTM demonstration

▶ Surgery:

• 10 minutes at resident half day, with Glo GermTM

• 10 minutes at staff division meeting

IMPLEMENTATION

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EFFECTS OF INTERVENTION


▶ Patient safety remains major concern in healthcare systems

▶ Successful implementation of safety change programs requires actors to change their behaviour(s)

▶ Insights from behavioural science can help optimise change programs and increase their likelihood of success

▶ CPSI and the Ottawa Centre for Implementation Research at the Ottawa Hospital Research Institute are planning a program to enhance capacity to use behavioural approaches to improve patient safety

SUMMARY


▶ Think about capacity development to use behavioural approaches within your group

▶ When planning safety initiatives: • Identify behaviour change needed to implement safety

procedures

• Identify barriers to behaviour change preferably using behavioural theory

• Consider assumptions and mechanisms to change when designing initatives

SUMMARY

[email protected] @GrimshawJeremy

mailto:[email protected]