Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 28

Commitment from the entire team was also key, beginning
with the attending physician. If an attending physician did
not prompt the checklist and the housestaff did not bring it
up, it did not get done. Twenty percent of housestaff provided
reasons for nonadherence that implied a lack of enthusiasm (i.e.,
forgot, did not pay attention, and too difficult). Accordingly,
it is important to educate the members of the team about the
importance of the quality improvement measure for improvement of patient care and patient outcomes. Quality improvement efforts must reach each team member. Our approach was
to foster coownership of healthcare quality by routinely sharing
patient outcomes potentially tied to the checklist with interns,
residents, nurses, floor clerks, and attending physicians.
Guidelines are useful only when they are followed. Applying
guidelines to daily practice can be difficult and resource intense.
In their systematic review, “Why Don’t Physicians Follow Clinical Practice Guidelines,” Cabana et al described three types of
barriers to guideline adherence: deficits in knowledge, attitude,
and behavior (7). Knowledge barriers are addressed by spreading
awareness and familiarity. We addressed this barrier through
e-mails, faculty meetings, presentations at conferences, and oneon-one meetings with the housestaff, which was a time- and
labor-intensive process. Attitude barriers include philosophical disagreements with the guidelines themselves or a culture
against guidelines in general, a lack of confidence in the ability of guidelines to achieve goals, and a lack of motivation or
inertia due to previous practices. We improved attitudes in a
few ways. First, prior to launching the initiative, we achieved
consensus with the hepatology faculty. Second, housestaff were
involved throughout the process and were regularly approached
for feedback and ideas to address any concerns or disagreement.
Behavioral barriers include time, resources, and functionality of
the guideline. Changing the location and color of the adherence
sheet saved time for the team.

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There are limitations to this study. First, while this study
took place over several months, the period is still short enough
that the rate of adherence could simply reflect the variable personalities and diligence of the housestaff involved. Second, as we
responded to problems with several simultaneous interventions,
it is impossible to disentangle the effect of each intervention.
Third, the potential impact of prophylactic measures started in
the hospital may be lower in resource-poor settings where patients are unable to afford such prescriptions. Fourth, this project presupposes the value of guideline-based checklists, which is
debatable. We believe, however, that the insights gleaned about
the pitfalls of quality improvement with housestaff should prove
generalizable, especially in the era of pay for performance and
the Affordable Care Act.
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Baylor University Medical Center Proceedings

Volume 27, Number 2