Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 26

Factors affecting adherence to a quality improvement checklist on an inpatient hepatology service Elliot B. Tapper, MD, and Michelle Lai, MD, MPH 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. ay for performance is here to stay, and central to the evolving reimbursement schema is the measurement of quality indicators, including adherence to practice guidelines. In the field of liver disease, low rates of guideline adherence represent a collective call to action. Prophylactic measures with proven mortality benefits are not being provided: 3% of patients eligible for primary prophylaxis of esophageal variceal hemorrhage receive optimal therapy, 12% of patients with cirrhosis receive liver cancer screening, and 30% of patients with a history of spontaneous bacterial peritonitis receive prophylactic antibiotics (1–3). Using expert consensus, Kanwal et al proffered a definition of quality care, building a set of “if . . . then” recommendations to be applied to specific ailments pertaining to cirrhosis management. For example, “If patients with cirrhosis present with or develop upper gastrointestinal bleeding, then they receive at least 1 large-bore intravenous line at the time of initial evaluation” (4). However, these recommendations require extensive interpretation to be applicable to daily practice, and measuring adherence to them demands readily available and complete patient information in a universal clinical language (5). To study adherence rates to guidelines and P 100 factors affecting adherence on our inpatient hepatology service, we examined adherence to a handheld checklist used on daily rounds (6). Herein, we present our study of the factors affecting adherence to this daily checklist. METHODS This single-center prospective observational quality improvement study took place on the dedicated inpatient hepatology unit of the Beth Israel Deaconess Medical Center in Boston, Massachusetts. Medical teams consist of an attending hepatologist, gastroenterology fellow, and two teams of a resident and intern, all of whom rotate on and off the service in 1- to 4-week blocks. The study tools included a checklist (Figure) and an adherence sheet. The goal was to review the medication administration record to ensure that patients were receiving medications as ordered and to check for medication errors. Additionally, the team was asked to consider and ensure that candidates for deep-vein thrombosis prophylaxis and esophageal variceal hemorrhage prophylaxis were receiving appropriate therapy. Protocols for the treatment of spontaneous bacterial peritonitis and hepatic encephalopathy were added to the checklist during phase 2. Upon completing the checklist, physicians were asked to initial an adherence sheet placed in the bedside chart. A survey was sent by e-mail to all housestaff to determine factors affecting adherence. The surveys included the ques tions “What percentage of the time did you (your team) go through the checklist on rounds? If it wasn’t done, why?” This was a two-phase study. During phase 1, which lasted 17 weeks, we implemented the checklist and adherence sheet and conducted surveys. The checklist components were based on faculty consensus achieved prior to the project rollout. The housestaff were informed and educated about the program before their rotation began. The adherence sheets were collected in the medical records department on discharge or transfer and From the Division of Gastroenterology (Tapper, Lai) and Department of Medicine (Tapper), Beth Israel Deaconess Medical Center, Boston, Massachusetts. Corresponding author: Elliot B. Tapper, MD, Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2014;27(2):100–102