Physician Explanations For Failing To Comply With "Best Practices"

Introduction
As the title indicates, this article is devoted to improving physician based compliance with evidence-based guidelines. To get more specific, the primary objective of this paper was to examine why physicians don't follow known "best practices" when treating patients with type 2 diabetes.

Method
The research design for this study was a descriptive study based upon self-assessed compliance. The research team consisted of 85 internists who volunteered to aid in conducting the study. The physicians were queried by the internists sending out 7,000 randomly generated survey requests (using a professional organization) and 800 of the 7,000 expressed interest and 137 went on to complete the task. In completing the survey, the physicians simply reviewed their own charts for type 2 diabetes patients and then reported open-ended comments for the reasons they did not comply with known "best practices".

Results/Conclusion
For diabetes care measures, the "physician noncompliance was most common for screening urinalysis(26%) and screening microalbuminuria (46%)" among the five measures examined. When examining the physicians open-ended comments, the main issues that were cited for noncompliance were physician oversight, patient non adherence, and systems issues. Physicians did admit that sometimes there is a conscious decision made to not comply due to the patient's age, comorbid illness or other factors. The study concludes that "even among a self-selected group of physicians, noncompliance with best practices in diabetes is common" and that physicians often disagree about what constitutes "best practice".

The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents

http://www.ahrq.gov/downloads/pub/advances/vol4/Meadows.pdf

Summary:

An Incident Decision Tree (IDT) was formulated to address patient safety issues arising in the United Kingdom. The IDT was developed by the National Health Service (NHS) in response to the alarming number of suspensions incurred by medical staff when patient safety issues arose.

The IDT provides human resource decision makers with a tool for determining the correct line of action when dealing with personnel in the wake of a patient safety issue. The overwhelming course of action before the IDT's implementation was a suspension for the health practitioner. The IDT proposes several different options for managers to consider after working their way through the tree. Applying the IDT allows the manager to implement fair and consistent actions resulting from patient safety mishaps.

The decision maker must think through the system and organization variables in the management of error from the prompts displayed throughout the tree. There are four consecutive trees a manager must consider about the situation. The first is the deliberate harm test (harm is intended), the incapacity test (the practitioner is sick, on medication, or has substance abuse problems), the foresight test (uncertain about protocal, protocal is unstated or poorly adhered to), and the substitution test (an equal would have acted differently). Each subsequent test is applied after the previous test was deemed inappropriate.

The pilot use of the IDT resulted in fewer suspensions for health care practitioners. Also, this lessened to a certain extent the "blame culture" associated with health care providers about self-reporting patient safety issues. Managers focused more on the "what" of the situation, rather than the "who."

A certain weakness was noted when human resource decision makers used the paper version of the IDT. Some decision makers chose suspension as the course of action and then worked backwards through the tree to justify their course of action.