judith dyson collaborative launch
DESCRIPTION
Achieving behaviour change for patient safety, Judith Dyson, Lecturer, Mental Health - University of Hull Presentation from the Patient Safety Collaborative launch event held in London on 14 October 2014 More information at http://www.nhsiq.nhs.uk/improvement-programmes/patient-safety/patient-safety-collaboratives.aspxTRANSCRIPT
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Achieving Behaviour Change for Patient safety
Dr Judith Dyson
Academic Improvement Fellow
Quality Improvement
Background
Lets first consider behaviour
• Health behaviour
• Patients concordance
• Implementation
What determines our behaviour?
What strategies do we generally employ to change?
Evidence tells us
• We need to assess individual barriers and levers
• We need to tailor our strategies according to these
• We need a theoretical approach to assessment and the intervention
• (Michie et al., 2005, Baker et al., 2010, MRC guidelines for complex interventions)
Psychological theory is useful
• Interventions designed based on theory have greater effects on behaviour than those that are not (Webb et al.,
2010; Taylor, Conner, & Lawton, 2012)
But tricky
Domain Meaning
Knowledge Does the person know they should be doing behaviour X? Do they understand?
Skills Does the person know how to do the behaviour (X)? How easy or difficult is it?
Beliefs about capabilities
How easy is it for the person to do X? Have they previously encountered problems? How confident are they that they can overcome difficulties?
Motivation and goals
How much do they want to do X? How much do they feel the need to do X? Are there incentives to do X? Are there competing priorities?
Environment To what extent do physical or resource factors hinder X? Time?
Beliefs about consequences
What do they think will happen if they do X? What are the costs/consequences of doing X? Does the evidence suggest that doing X is a good thing?
Emotion Does doing X evoke an emotional response? To what extent do emotional factors help or hinder X? How does emotion affect X?
Social influences To what extent do social influences help or hinder X? Will the person observe others doing X?
Memory/attention Can the person remember to do behaviour X? Do they usually do X?
Action planning Does the person put plans in place to ensure they do the behaviour?
Made Easy - the TDF Theoretical Domains Framework Michie et al. 2005
Stepped process informed by behaviour change theory and implementation literature
(Michie et al., 2005, 2008; Grol et al., 2007)
Involve stakeholders
Medical directors and
sharp end staff
Identify target
behaviour
Audit and discussion
Identify barriers
Influences on Patient Safety
Behaviours Questionnaire
(IPSBQ)
Confirm barriers and generate intervention
strategies
Focus groups
Support staff to implement and
evaluate intervention
Joint approach
Re-auditing
Further progress The Theoretical Domains Framework Implementation (TDFI) approach
(Taylor et al., 2013)
Questionnaire results Barriers ‘to using pH as the first line method for checking tube position’
Barrier
Mean (SD)
H1
n = 99
Mean (SD)
H2
n =105
Mean (SD)
H3
n =23
Mean (SD)
all hospitals
n = 227
Inter-item
correlation
Knowledge 2.02 (0.70) 2.33 (0.75) 2.08 (0.76) 2.17 (0.74)** 0.64
Skills 2.37 (0.79) 2.64 (0.72) 2.74 (0.87) 2.53 (0.78)** 0.62
Social and professional identity 2.04 (0.73) 1.96 (0.64) 2.16 (0.79) 2.01 (0.69) 0.23
Beliefs about capabilities 2.44 (0.77) 2.55 (0.83) 2.52 (0.97) 2.50 (0.81) 0.43
Beliefs about consequences 2.35 (0.70) 2.38 (0.70) 2.39 (0.48) 2.37 (0.68) 0.45
Motivation and goals 2.40 (0.66) 2.40 (0.60) 2.65 (0.69) 2.42 (0.64) 0.21
Cognitive processes, memory
and decision making 2.36 (0.68)
2.47 (0.74)
2.19 (0.67)
2.39 (0.71) 0.23
Environmental context and
resources 2.55 (0.85)
2.69 (0.69)
2.68 (0.62
2.63 (0.76) 0.47
Social influences 2.84 (0.76) 2.89 (0.73) 2.71 (0.75) 2.85 (0.74) 0.22
Emotion 2.41 (0.65) 2.75 (0.55) 2.35 (0.62) 2.56 (0.63)* 0.62
Action Planning 2.32 (0.66) 2.38 (0.62) 2.42 (0.54) 2.36 (0.63) 0.43
Focus group results: interventions matched to barriers and BCTs (H1)
Barrier Strategy Behaviour change technique*
Social
influences
• Information presented at clinical governance
meetings by experts in the area
• Awareness day held within the Trust
• Posters with pictures of senior staff performing
correct behaviour
• Persuasive source
• Information about health
consequences, and social/
environmental consequences
• Prompts, cues, social support
(unspecified)
Emotion • Screensaver contained messages to elicit
anticipated regret and to reframe perspective on
behaviour
• Anticipated regret
• Salience of consequences
• Framing/reframing
Environmental
context and
resources
• Radiology and ward protocols to empower staff
• Instructions, flow chart, measurement tool, who
placed NG, place to record pH values, etc.
• Splashscreen placed on intranet with prompt about
pH testing and link to all relevant documentation
• Prompts, triggers, cues
• Adding objects to the
environment
Bcap (and
knowledge and
skills)
• Practical training complete for current FY1s
• E-learning package developed for junior doctors
• Instruction on how to perform a
behaviour
• Behavioural practice/rehearsal
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% of patients with NG feeding tubes who had pH testing as the first line test method following
insertion
% total numbers
% minus theatre
March 2011:revised
Sept & Oct 2011: project
presented at 4 clinical audit
meetings
October 2011; FY1
doctors attend
June 11: new
trust NGT
documentation
February 4th 2012;
screen saver
launched with an
awareness day
Junior doctor
Practice change results
Audit information
Hospital 1 Hospital 2 Hospital 3 Hospital 4
(Control)
Pre Post Pre Post Pre Post Pre Post
Number of sets of notes
audited 49 48 43 44 44 40 53 46
pH of aspirate from stomach 18% 63% 12% 73% 14% 33% 45% 46%
Patient sent for X-ray 49% 23% 77% 9% 41% 40% 25% 20%
Tube placed in radiology 0 0 0 0 36% 10% 0 0
Information not documented 33% 15% 9% 18% 9% 18% 30% 46%
Target behaviour: Using pH as the first line method for checking tube position
Other examples using framework
• Hand hygiene (Dyson et al., 2013)
• Low back pain management in primary care (French et al., 2012)
• Management of mild traumatic brain injury in the emergency department (Knott et al., 2014)
• Tobacco cessation counselling by oral health professionals (Amemori et al., 2013)
• Midwives engaging with pregnant women in discussions about smoking (Boenstock et al., 2012)
• Development of an intervention to promote activity in care homes (ongoing work at BIHR)
Putting it into practice
• The improvement academy
• Behaviour change workshops
• The toolkit
• My role within the academy
Workshops
Where to find the toolkit
The 6 steps
Me
Worked examples
www.improvementacademy.org
My role
• “It’s all about urine”
• Electronic monitoring of HH
• Safer dispensing
• Medicines on care transfer
• Sepsis bundle
• Restructuring of teams
• Falling
“It’s all about urine”
• Background
– UTI second largest group of HCAIs in the UK (HPA 2009)
– Concern with inappropriate antibiotic prescription for suspected UTIs
– Maurice did an audit . . . . . . . . .
Steps 1 and 2
Identifying the behaviour – not easy
• Inappropriate dip stick testing (e.g. catheter, e.g. no UTI symptoms)
• Antibiotic prescribing without MSU
• Antibiotic prescribing not in line with policy (e.g. Cefalexin 2nd line due to C diff being Rx 1st line)
• Not all positive dipstick results followed up by MSU
• Prescriptions for antibiotics 3 days or less. . . . .
Understanding Barriers
Validity and Reliability
What do you think the barriers are?
• Sending an MSU after a dipstick when nursing assistants discover leucocytes and nitrates?
Next steps
Devising interventions
Defined and with examples
Behaviour change techniques for specific barriers
Implement. . . .Evaluate
Evaluate
• Table (behaviour change)
• Run chart (behaviour change)
• Barriers before and after
• Impact on outcomes (e.g. MRSA, falls)
Is this approach helpful? Weaknesses?
• It is for us
• ?difficult to navigate and understand
• Formal evaluation
• There is more info’ . . . . balance
• Keeping things current
Is this approach helpful? Strengths
• Flexibility e.g number of domains included/relevant
• Flexibility – use for patient interventions (exercise, MOLES, PEEP)
• Flexibility – in reverse (e.g. PEEP, another (local) electronic HH monitoring study)
• Large body of evidence, literature, experience – further pushing the boundaries
• The future . . . . further spread . . . your thoughts
Thank you
Any questions?
Feel free to contact me: Judith Dyson [email protected]
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