Table 2 Behavior Change Wheel (BCW) framework for adoption of guideline-based clinical practice at ORCI
Barriers | COM-B category | Intervention functions | Behavior change techniques and mode of delivery |
|---|---|---|---|
Guidelines not easily accessible | Physical capability | Enablement | Distribute hard copies to every unit and clinic room, soft copies to every provider (via smartphone application). Include algorithms as a reference in clinical “Diagnosis, Staging, Treatment” (DST) forms. |
Lack of knowledge of guideline content | Psychological capability | Education | Teach guideline content, including evidence basis for guidelines, to providers in dedicated education session and integrate into existing curriculum for residents and nurses. |
Lack of experience in guideline-based practice | Psychological capability | Training, environmental restructuring | Administer skills training in how to use guidelines and DST forms in dedicated trainings. Integrate clinical forms into a workflow that prompt providers to apply guidelines to every patient. |
Providers not aware or do not believe that they should be following guidelines | Psychological capability | Education Persuasion Modeling | Publicity campaign using branding, awareness raising of regional and international efforts to develop LMIC-specific guidelines. Selected local Champions will persuade providers that they should adhere to guidelines, and model this behavior during morning conference and in clinical practice. |
Consultant/resident/nurse not together when plan is made | Physical opportunity | Environmental restructuring | Team members, including residents and nurses, should round together and review guideline concordance of treatment plan, review with consultant. |
Lack of accountability in patient management | Physical opportunity | Environmental restructuring | DST forms will be completed for every patient, with documentation of rationale for treatment decisions. One consultant should be assigned to each patient at intake and ultimately responsible for treatment plan. |
Current norm is that consultants make decisions based on expertise | Social opportunity | Training Modeling | Champions will model guideline-based practice on an ongoing basis on rounds/in conference. All providers (consultants, residents, nurses) will be trained to discuss or question the guideline concordance of their patients’ treatment plans. Champions will also model this behavior. |
Little professional value placed on guideline concordance | Social opportunity | Incentivization | Champions will provide recognition and praise for guideline-concordant management. Planned outcomes evaluation will include audit and feedback. |
Belief that expertise-based decisions are better than guidelines | Reflective motivation | Training Persuasion | Train providers in the benefits of guideline-based practice and provide evidence that they should be used in favor of expert opinion. |