Executive Summary
This study examines a complex interplay of issues contributing to slow and partial compliance with evidence-based clinical guidelines. It focuses on guidelines for management of severe traumatic brain injury (TBI), which were first issued a decade ago and are revised every five years. Because severe head trauma enlists so many providers and often involves injury to multiple body systems, it maximizes the challenges of delivering timely, consistent, and coordinated care across the boundaries of disciplines, departments, hospital units, and lines of authority. Management of TBI thus offers a valuable perspective on the structural problems that impede the delivery of care and the implementation of clinical guidelines.
This is not a clinical study, but rather a study about change processes in complex clinical environments. Based on case studies and interviews with many physicians and nurses as well as a few academics, policymakers, and consultants, it identifies barriers to compliance with TBI guidelines, describes how three trauma centers lowered or overcame such barriers, and identifies common threads in their approaches.
Barriers to TBI Guidelines Implementation
Three types of barriers hinder implementation of TBI Guidelines: the macro-environment of trauma care, structural and organizational factors, and professional and personal factors.
Macro-Environmental Factors. The macro-environment—the financial, regulatory, and organizational context of trauma care—does not support trauma centers' investment in guidelines implementation. The trauma system itself and many of its trauma centers face significant financial challenges, putting their viability into question and impeding the reforms needed to implement the TBI Guidelines.
- Payment structures and levels do not match the costs of trauma care.
- Low volume plagues many centers, making it difficult to cover the high standby costs.
- At other centers, high volumes of uninsured trauma patients justify the standby costs but still generate losses for the center overall.
Structural and Organizational Factors. The management of TBI is embedded in the structures of medical practice through which trauma care in general and TBI care in particular is delivered. Guidelines are introduced into clinical environments that are organized by medical specializations and the territorial issues that grow up around the various specializations.
- The segmentation of trauma care—with different providers making treatment decisions at different stages of care—is resistant and even antithetical to achievement of integrated TBI care consistent with the Guidelines.
- At every boundary between units, disciplines, and departments, there is potential for breakdowns in the continuity of care and barriers to implementation of the Guidelines.
Professional and Personal Factors. Although some physicians have taken leadership roles in aligning clinical practice with TBI Guidelines, physicians are, by all accounts, the primary locus of resistance. They are the point through which professional traditions, the imperatives of private practice, and structural barriers converge. Certain of their choices and behaviors are at the heart of what must change for TBI Guidelines to be effectively implemented.
- Treatment for trauma is becoming less rooted in surgery and thus—given the bias of payment codes toward surgery—less well reimbursed. Therefore, physicians are reluctant to take trauma calls and residents are turning away from trauma specialization.
- Physicians experience conflicts between treating trauma patients and conducting the rest of their professional lives. Further, treating trauma patients impinges on physicians' private lives.
Learning from Successful Implementation
Guidelines implementation requires organizational changes in clinical settings. Changes in clinical practice among the network of clinicians treating TBI patients are necessary but not sufficient. Clinicians from different specialties and different professions must also work together to improve communication, collaboration, and coordination of care.
The fragmented structure of trauma care must be counterbalanced by an equally powerful set of forces for integration. This requires investing in nursing and physician roles that have strong integration, coordination, and communication dimensions. Effective implementation requires several forms of leadership: physician champions, administrative and high-level medical support, and hands-on change agents.
- At least one leader from neurosurgery or trauma must be committed and persistent, and they must enlist at least one key ally from the other discipline.
- Although it is possible to implement the Guidelines without a clinical nurse specialist as the empowered change agent orchestrating the process on a daily basis, it is more difficult and appears to take much more time.
Key strategies for overcoming structural and organizational barriers as well as various forms of resistance include:
- limiting the number of people in the trauma network;
- translating each recommendation into protocols detailing how they are to be enacted;
- designing pathways and protocols with providers as well as patients in mind;
- redeploying staff to leverage their contributions;
- making changes in critical care units and/or management of such units;
- framing implementation as a research and learning opportunity; and
- enlisting, managing, and leveraging the scarce, often reluctant, neurosurgical resources.
Other factors in successful implementation include: increasing the degree of organizational readiness for change; undertaking a comprehensive change process that is both systematic and systemic; implementing an educational process that is comprehensive, ongoing, and tailored to individuals in the course of their work; and having mechanisms in place and enough resources available to sustain the changes and continue to improve.
