EBP Step 4

Implementation of evidence into practice
Barriers and enablers
Strategies

Implementation of evidence into practice

Appropriateness of care

How appropriate is the health care received by individuals? A recent study in Australia showed that, of the 35,573 health care encounters, only 57% received appropriate care. According to this study, for health practitioners with more than 300 encounters overall compliance with indicators of appropriate care ranged from 32% to 86% (Runciman et al 2012)

Reference

Runciman WB, Hunt T, Hannaford NA, Hibbert P, Westbrook J, Coiera E, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust 2012; 197(2):100-105.

Changes to health care

According to the Institute of Medicine report [Crossing the Quality Chasm: A New Health System for the 21st Century] in 2001, health care should be underpinned by safe, effective, efficient, patient-centred, timely and equitable process.
Allied health practitioners are increasingly mandated to practice the principles of EBP as a means for improving the quality of health care.

Gap between research evidence and clinical practice

Does access to, and availability of, high quality research evidence equate to implementation of evidence into practice? NO

Many patients (30% – 40%) do not receive the recommended care
Many patients (20%) receive diagnostic tests or medications which are not evidence based, unnecessary and potentially harmful
Poor safety and quality of health care services partly due to lack of using evidence based guidelines

Reference

Grol R and Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust 2004; 180:S57-S60.

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Barriers and enablers

Experts in the field of evidence implementation suggest that an in-depth and comprehensive approach to identifying barriers and enablers is key to achieving change in clinical practice, thereby closing the gap between research and practice. Grol and Wensing (2004) proposed that barriers and enablers be assessed at six different levels of healthcare: the change or innovation itself, individual practitioner, patient, social context, organisational context, and economic and political context.

Level	Barriers/enablers
The change or innovation	Advantages in practice, feasibility, credibility, accessibility, attractiveness
Individual practitioner	Awareness, knowledge, attitude, motivation to change, behavioural routines
Patient	Knowledge, skills, attitude, compliance
Social context	Opinion of colleagues, culture of the network, collaboration, leadership
Organisational context	Organisation of care processes, staff, capacities, resources, structures
Economic and political context	Financial arrangements, regulations, policies

The following resource provides basic information about the techniques that can be used to examine barriers, and tools to assist with identifying barriers to change.

Reference

National Institute of Clinical Studies. Identifying barriers to evidence uptake. Melbourne Victoria; 2006.

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Strategies

In choosing interventions that will facilitate implementation of evidence into practice, Grimshaw et al (2012) suggests the identification of modifiable and non-modifiable barriers relating to practice behaviour, identification of potential adopters and practice environments, and prioritisation of barriers to target based on consideration of ‘critical’ barriers. The potential for addressing the barriers through the use of evidence implementation interventions and the resources available should also be examined.

Strategies	What they are
Printed educational materials	Distribution of published or printed recommendations for clinical care (i.e. clinical practice guidelines, audio-visual materials and electronic publications] Aimed at improving knowledge and skill gaps in individual health practitioners Relatively low cost; feasible in most settings
Educational meetings	Participation of healthcare providers in conferences, lectures, workshops or traineeships Can be didactic meetings (can improve knowledge in individual healthcare practitioner/peer group level) or interactive workshops (can improve knowledge, attitudes, and skills in individual healthcare practitioner/peer group level) Feasible in most settings
Outreach visits or academic detailing	Use of a trained person who meets with practitioners in their practice settings to give information (may include feedback on the performance of the practitioners) with the intent of changing the providers’ practice Typically the visit is aimed at conveying a maximum of three messages across during a 10-15 minute meeting with a practitioner The approach is tailored to the characteristics of the individual practitioner; involves the use of additional strategies to reinforce the message Require considerable resources
Local opinion leaders	Use of practitioners nominated by their colleagues as ‘educationally influential’ An opinion leader (i.e. practitioner who is ‘educationally influential’) has influential position in their system’s structure, and is at the centre of interpersonal communication networks. This ‘title’ is earned based on technical competence, social accessibility and conformity to the systems norms Resources required: cost of the identification method, training of opinion leaders, additional service cost
Audit and feedback	Any summary of clinical performance of clinical performance of healthcare over a specified period of time to change practice behaviour Clinical performance information may be obtained from medical records, computerised databases or observations from patients The subsequent feedback of and resulting action planning based on the audit summary is an important element of this intervention Resources required: data abstraction, analysis costs and dissemination costs
Reminders	Patient or encounter specific information provided verbally, on paper or on a computer screen designed or intended to prompt a health practitioner to recall information Reminders serve as prompts to healthcare practitioners to remember to do important items during practitioner-patient interactions Resources required: vary according to the delivery method
Tailored interventions	Strategies to improve professional practice that are planned, taking account of prospectively identified barriers to change
Multifaceted interventions	Any intervention including two or more components which potentially target different barriers in the system Likely to be more costly that single interventions