This document discusses using behavioral science approaches to improve patient safety programs. It describes a partnership between the Canadian Patient Safety Institute (CPSI) and the Ottawa Centre for Implementation Research to increase the use of behavioral approaches in designing effective change programs. As an example, it outlines a study that used interviews and observations to identify barriers to physician hand hygiene, designed an intervention to address key behavioral domains, and implemented different strategies for medical and surgical staff. The goal is to help organizations optimize change programs and patient safety initiatives through incorporating insights from behavioral science.

1. www.ohri.ca | Affiliated with • Affilié à
IT’S NOT (JUST) WHAT
YOU DO, IT’S (ALSO)
HOW YOU DO IT!
JEREMY GRIMSHAW
SENIOR SCIENTIST AND PROFESSOR
KATHRYN SUH, MD, FRCPC
6TH OCT. 2016
jgrimshaw@ohri.ca
@GrimshawJeremy

2. WHO WE ARE
Dr Kathryn Suh
▶ Medical Director, Infection
Prevention and Control Program
and Antimicrobial Stewardship
Program, The Ottawa Hospital
▶ Associate Professor of Medicine,
University of Ottawa.
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Dr Jeremy Grimshaw
▶ Senior Scientist, Ottawa Hospital
Research Institute
▶ Professor of Medicine, University
of Ottawa

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▶ Ensuring patient safety remains a high priority for
healthcare systems, organisations and providers
▶ The Canadian Patient Safety Institute has been at the
forefront of efforts to promote safety in Canadian
Healthcare settings and has achieved substantial
improvements in patient safety.
▶ However, there remain substantial challenges to
implement patient safety practices.
▶ Shift to Safety, the newest program of CPSI is
launching a new initiative to promote the use of
behavioral approaches in patient safety initiatives.
BACKGROUND
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▶ Successful implementation of patient safety programs
needs key actors (patients, healthcare providers,
managers and policy makers) to change their
behaviours and/or decisions whilst working in the
complex (ordered chaos) of health care environments
▶ There is a substantial evidence base in behavioural
sciences that can support the development of patient
safety programs and increase the likelihood of success
BEHAVIOURAL PERSPECTIVE

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▶ The Ottawa Centre for Implementation Research at the
Ottawa Hospital Research Institute is an
interdisciplinary group that undertakes research on
behavioural approaches to enhance change programs
▶ We are partnering with CPSI to increase the Canadian
capacity to use behavioral approaches to optimise
change programs.
OTTAWA CENTRE FOR IMPLEMENTATION RESEARCH
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▶ Angel Arnaout, surgery, disinvestment in cancer
▶ Sylvain Boet, anesthesiologist, medical education
▶ Jamie Brehaut, cognitive psychologist
▶ Ian Graham, medical sociology
▶ David Moher, epidemiologist, knowledge syntheses
▶ Justin Presseau, health psychologist
▶ Janet Squires, nursing, implementation science
▶ Dawn Stacey, nursing shared decision making
▶ Monica Taljaard, biostatistician
▶ Kednapa Thavorn, health economist
▶ Noah Ivers, family physician, implementation science (Toronto)
▶ Holly Witteman, engineering, human factors (Quebec City)
OTTAWA CENTRE FOR IMPLEMENTATION RESEARCH
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7. DESIGNING CHANGE PROGRAMS

8. Who needs to do
what differently?
Using a theoretical framework,
which barriers and enablers need
to be addressed?
Which intervention components
could overcome the modifiable
barriers and enhance the enablers?
How will we measure
behaviour change?
DESIGNING CHANGE PROGRAMS

9. Who needs to do
what differently?
Using a theoretical framework,
which barriers and enablers need
to be addressed?
Which intervention components
could overcome the modifiable
barriers and enhance the enablers?
How will we measure
behaviour change?
DESIGNING CHANGE PROGRAMS

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▶ Specify behaviour using TACTA principle
▶ Identify:
• What needs to be done (Action)
• By whom (Actor)
• To whom (Target)
• Where (Context)
• When (Time)
DESIGNING CHANGE PROGRAMS
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▶ What needs to be done (Action)
• Hand hygiene
▶ By whom (Actor)
• All health care providers
▶ To whom (Target)
▶ Where (Context)
• Clinical environments
▶ When (Time)
• Four moments of hand hygiene
DESIGNING CHANGE PROGRAMS
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12. Who needs to do
what differently?
Using a theoretical framework,
which barriers and enablers need
to be addressed?
Which intervention components
could overcome the modifiable
barriers and enhance the enablers?
How will we measure
behaviour change?
DESIGNING IMPLEMENTATION PROGRAMS

13. THEORETICAL DOMAINS FRAMEWORK

14. THEORETICAL DOMAINS FRAMEWORK
Michie 2005
 Knowledge
 Skills
 Social/professional role
and identity
 Beliefs about capabilities
 Beliefs about
consequences
 Motivation and goals
 Memory, attention and decision
processes
 Environmental context and
resources
 Social influences
 Emotional regulation
 Behavioural regulation
 Nature of the behaviour

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THEORETICAL DOMAINS FRAMEWORK

16. THEORETICAL DOMAINS FRAMEWORK
Michie 2005
 Knowledge
 Skills
 Social/professional role
and identity
 Beliefs about capabilities
 Beliefs about
consequences
 Motivation and goals
 Memory, attention and decision
processes
 Environmental context and
resources
 Social influences
 Emotional regulation
 Behavioural regulation
 Nature of the behaviour

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Key beliefs:
▶ conflicting comments about who was responsible for the test-
ordering (Social/professional role and identity);
▶ inability to cancel tests ordered by fellow physicians (Beliefs about
capabilities and social influences);
▶ problem with tests being completed before the anesthesiologists
see the patient (Beliefs about capabilities and Environmental
context and resources).
▶ tests were ordered by an anesthesiologist based on who may be
the attending anesthesiologist on the day of surgery while
surgeons ordered tests they thought anesthesiologists may need
(Social influences).
THEORETICAL DOMAINS FRAMEWORK
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18. Who needs to do
what differently?
Using a theoretical framework,
which barriers and enablers need
to be addressed?
Which intervention components
could overcome the modifiable
barriers and enhance the enablers?
How will we measure
behaviour change?
DESIGNING CHANGE PROGRAMS

19. DESIGNING IMPLEMENTATION PROGRAMS

21. ▶ Graded tasks - Set easy
tasks, and increase
difficulty until target
behavior is performed.
▶ Behavioural
rehearsal/practice -
Prompt the person to
rehearse and repeat the
behavior or preparatory
behaviors
DESIGNING IMPLEMENTATION PROGRAMS

22. DESIGNING IMPLEMENTATION PROGRAMS

24. BEWARE
POOR
DESIGN

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A PRACTICAL STUDY: PHYSICIAN HAND
HYGIENE
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▶ Healthcare-associated infections are one of the top 10
causes of hospital deaths worldwide
• affect 10% of all patients in acute-care hospitals
▶ Physician hand hygiene compliance is an international
problem
• Average reported compliance rate: 49-57%
▶ Reasons for poor compliance not well understood

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A PRACTICAL STUDY: PHYSICIAN HAND
HYGIENE
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ASSESSING BARRIERS AND ENABLERS
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▶ Key informant interviews with 42 staff physicians and
residents in Medicine, Surgery
▶ Two focus groups with four institutional hand hygiene
“experts”: hand hygiene auditors, infection prevention
and control professionals, and Senior Management
▶ Observation of hand hygiene and audits on inpatient
Medicine and Surgery units

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▶ Knowledge: I am / am not aware of hand hygiene
guidelines
▶ Skills: I have / have not had training in hand hygiene
techniques
▶ Beliefs about consequences: hand hygiene reduces
transmission of infection
▶ Memory and attention: reminders are / are not useful
for hand hygiene
▶ Social influence: others on my team do / do not
influence my hand hygiene behaviour
INTERVIEW GUIDE
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 Knowledge
 Skills
 Social/professional role
and identity
 Beliefs about
capabilities
 Beliefs about
consequences
 Motivation and goals
THEORETICAL DOMAINS FRAMEWORK
 Memory, attention and
decision processes
 Environmental context
and resources
 Social influences
 Emotional regulation
 Behavioural regulation
 Nature of the behaviour

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▶ Important TDF domains were prioritized with team
input, and mapped to known effective behaviour
change techniques
▶ Intervention focused on five prioritized domains,
considering feasibility in our environment, and
acceptability to the “actors”
• Knowledge; skills; beliefs about consequences;
memory, attention and decision processes; social
influences
▶ Intervention delivery differed for medicine and
surgery
INTERVENTION MAPPING AND DESIGN

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▶ Based on assessment of barriers, resources, practical
aspects of implementation
▶ Medicine:
• Two slides for resident orientation
• Four x 2 minute sessions during stewardship rounds
• Glo GermTM demonstration
▶ Surgery:
• 10 minutes at resident half day, with Glo GermTM
• 10 minutes at staff division meeting
IMPLEMENTATION
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32. EFFECTS OF INTERVENTION

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▶ Patient safety remains major concern in healthcare
systems
▶ Successful implementation of safety change programs
requires actors to change their behaviour(s)
▶ Insights from behavioural science can help optimise
change programs and increase their likelihood of
success
▶ CPSI and the Ottawa Centre for Implementation
Research at the Ottawa Hospital Research Institute are
planning a program to enhance capacity to use
behavioural approaches to improve patient safety
SUMMARY

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▶ Think about capacity development to use behavioural
approaches within your group
▶ When planning safety initiatives:
• Identify behaviour change needed to implement safety
procedures
• Identify barriers to behaviour change preferably using
behavioural theory
• Consider assumptions and mechanisms to change when
designing initatives
SUMMARY

35. jgrimshaw@ohri.ca
@GrimshawJeremy