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Qual Saf Health Care 2008;17:351-359 doi:10.1136/qshc.2006.021709
  • Error management

Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections

  1. A P Gurses1,
  2. K L Seidl2,
  3. V Vaidya3,
  4. G Bochicchio4,5,6,
  5. A D Harris2,7,
  6. J Hebden8,
  7. Y Xiao5,9
  1. 1
    Division of Health Policy and Management, University of Minnesota, Minneapolis, Minnesota, USA
  2. 2
    University of Maryland Medical Center, Baltimore, Maryland, USA
  3. 3
    Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
  4. 4
    Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
  5. 5
    Program in Trauma, University of Maryland, Baltimore, Maryland, USA
  6. 6
    Veterans Affairs Medical Center, Baltimore, Maryland, USA
  7. 7
    Department of Epidemiology and Preventive Medicine, University of Maryland, Baltimore, Maryland, USA
  8. 8
    Infection Control and Hospital Epidemiology, University of Maryland Medical Center, Baltimore, Maryland, USA
  9. 9
    Department of Anesthesiology, University of Maryland, Baltimore, Maryland, USA
  1. A P Gurses, Division of Health Policy and Management, University of Minnesota, 420 Delaware Street SE, Mayo Mail Code 729, Minneapolis, MN 55455, USA; gurse001{at}umn.edu
  • Accepted 19 September 2007

Abstract

Background: Consistent compliance with evidence-based guidelines is challenging yet critical to patient safety. We conducted a qualitative study to explore the underlying causes for non-compliance with evidence-based guidelines aimed at preventing four types of healthcare-associated infections in the surgical intensive care unit (SICU) setting.

Methods: Twenty semistructured interviews were conducted with attending physicians (3), residents (2), nurses (6), quality improvement coordinators (3), infection control practitioners (2), respiratory therapists (2) and pharmacists (2) in two SICUs. Using a grounded theory approach, we performed thematic analyses of the interviews.

Results: The concept of systems ambiguity to explain non-compliance with evidence-based guidelines emerged from the data. Ambiguities hindering consistent compliance were related to tasks, responsibilities, methods, expectations and exceptions. Strategies reported to reduce ambiguity included clarification of expectations from care providers with respect to guideline compliance through education, use of visual cues to indicate the status of patients with respect to a particular guideline, development of tools that provide an overview of information critical for guideline compliance, use of standardised orders, clarification of roles of care providers and use of decision-support tools.

Conclusions: The concept of systems ambiguity is useful to understand causes of non-compliance with evidence-based guidelines aimed at reducing healthcare-associated infections. Multi-faceted interventions are needed to reduce different ambiguity types, hence to improve guideline compliance.

Footnotes

  • Funding: This work was funded by the National Science Foundation (IIS-0534646). The opinions are of those authors and do not necessarily reflect the sponsor’s official position.

  • Competing interests: None declared.

  • Ethics approval: Ethics approval was obtained.

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