AARC Barriers to Protocol Implementation Survey Results A Project of the AARC Protocol Implementation Committee 2008 Slides developed to adjunct lectures supporting the use of respiratory care protocols Survey Background In order to better develop a plan for the implementation and use of protocols the committee recognized that barriers exist Survey tools were developed to assess these barriers and perceptions Separate surveys were developed for both the Manager and Staff Therapist This slide presentation was developed from those surveys and is intended to assist in understanding the barriers and developing successful strategies to implement protocols Protocol Definition For the purpose of both the Manager and Staff surveys, protocols were defined as: Initiation or modification of a patient care plan
following a predetermined structured set of physician orders, instructions or interventions in which the therapist is allowed to initiate, discontinue, refine, transition, or restart therapy as the patient's medical condition dictates. Note: This definition should not be confused with programs that include discontinuation of therapy without a reorder, flagging therapy for physician reorder, standing orders or policies that dictate therapy durations. Respondents Region - Manager Survey 459 respondents (post cards and email) In which U.S. census region is your hospital located? New England Middle Atlantic East North Central West North Central South Atlantic East South Central West South Central Mountain Pacific
Demographics Manager Survey Location of your hospital 40% 35% 30% 25% Rural 20% Suburban 15% Urban 10% 5% 0% 1 Hospital Type - Manager Survey Describe your hospital's type of ownership Investor owned (for-profit)
The majority were not for profit hospitals Non-Government not-forprofit Government-Federal Government-Non-Federal 0% 10% 20% 30% 40% 50% 60% 70% Number of staffed beds supported by your hospital 401 or more
Evenly split between small and large hospitals 24% 201-400 26% 23% 101-200 Less than 100 21% 27% 22% 23% 24% 25% 26% 27%
28% Department Profile - Manager Survey Mostly hospitals with < 25 FTEs What is the total number of respiratory therapist FTEs? 35% 30% 25% 20% 15% 10% 5% 0% Less than 10 11 25 26-50 51-75
76-100 More than 100 Does your hospital have protocols in place as described in the definition above? The majority have at least one protocol as described Yes No Protocol Use - Manager Survey Does your hospital have protocols in place as described in the definition above? More than 10 The majority of hospitals do not have a comprehensive protocol program. 5 to 10 1 to 5
0% 10% 20% 30% 40% 50% 60% What is your estimate of the percent of respiratory therapy provided by protocol at your institution? Less than 50% of care is provided by protocols despite the evidence that protocols improve outcomes and reduce cost. Not applicable 76-100
51-75 26-50 0-25 0% 5% 10% 15% 20% 25% 30% 35% 40% Types of Protocols in Place - Manager Survey 70% 64%
Lung hyperinflation Bronchodilator therapy Disease-based Mechanical ventilation Not applicable An even mix of complex and simple protocols. Medical Staff Order Practices Manager Survey Estimate the percent of your medical staff who routinely order respiratory therapy by protocol 45% 40% 35% 30% 25% 20% 15% 10%
5% 0% 0-25 26-50 51-75 76-100 Not applicable If you add the N/A (meaning they dont have protocols established for physicians to order) to the 0-25% category, that is the majority of physicians. Manager Perception of Medical Staff Opinion Staff Physicians 40% 35% 30% Are opposed 25%
Are concerned that the therapists don't have the skills required Are unaware of the clinical and economic benefits Perceive they would lose control 20% 15% 10% 5% 0% Extremely significant Somewhat significant Not significant Many physicians are opposed or perceive they would lose control. The Manager Survey Indicates the Following are NOT Barriers
The medical directors of departments The managers of the department The nurses The administrators Managers Perceive the Barrier as It was apparent from the survey that the medical directors and managers felt that a portion of the barrier was that RT didnt have the skills to function under protocols That perception MUST change.. Staff Surveys Surveys were emailed to all identified as staff therapists in the AARC member database with1705 responses The following slides represent the perceptions of staff therapist of administration, medical staff, nurses and themselves Respondents Region - Staff Survey
U.S. Census Region #2 Middle Atlantic 10% 6% 10% 6% 5% 23% #1 New England 16% #3 East North Central #4 West North Central 14% 10% #5 South Atlantic #6 East South Central #7 West South Central #8 Mountain #9 Pacific
25% 20% 15% 10% 5% 0% Less than 100 101-200 201-400 401 or more Hospital Type - Staff Survey Hospital Type of Ownership Investor Owned for Profit Same as managers survey, the majority are not-for-profit. Non-Government not-for-profit (church affiliated, etc.)
Government owned Government-Non-Federal (state, county,city-county, communityowned, etc.) 0% 20% 40% 60% Is this hospital affiliated with a medical school? 70% Most are not affiliated with a medical school. 60% 50% 40% 30% 20% 10% 0%
Yes No Do You Have Protocols? - Staff Survey Protocols Established No Yes 0% 10% 20% 30% 40% 50% 60% 70%
80% Although staff reports most departments having protocols, the manager survey shows most do not have a comprehensive protocol system. Staff Perception of Managers as Barriers Staff do not view a manager as a significant barrier. Staff Perceptions of Medical Staff as Barriers Perceive they would lose control of the treatment provided to their patients if protocols were implemented. Are unaware of the clinical and economic benefits of implementing protocols. 1-Not significant 2 3 4 5-Extremely significant Are concerned that the therapists don't
have the skills required to implement protocols. Are opposed to care being delivered by protocol. 0 100 200 300 400 500 600 Staff perceive physicians sense a loss of control as a significant barrier. Staff Perception of Medical Directors as Barriers Percieves they would lose control of the treatment provided to their patients if protocols were implemented. Is unaware of the clinical and economic benefits of implementing protocols. 1-Not significant 2 3 4 5-Extremely significant
Is concerned that the therapists don't have the skills required to implement protocols. Is opposed to care being delivered by protocol. 0 100 200 300 400 500 600 Medical directors do not pose a significant barrier to protocols Staff Perceptions of Nurses as Barriers 600 500 5-Extremely significant
400 4 300 3 200 2 100 1-Not significant 0 Is opposed to care being delivered by protocol. Is concerned that the therapists don't have the skills required to implement protocols.
Is unaware of the clinical and economic benefits of implementing protocols. Nurses are not perceived as a significant barrier for most staff. Staff Perception of Respiratory Therapist as Barriers 800 700 600 500 400 300 200 100 0 5-Extremely significant 4 3 2 1-Not significant
Are opposed to care being delivered by protocol. Don't have the skills required to implement protocols. Are unaware of the clinical and economic benefits of implementing protocols. Are concerned that staff would be reduced if protocols were implemented. Respiratory therapists do not view themselves as a significant barrier Willingness to Learn Another Skill if Protocols
Reduce the Need for RTs? Staff Survey Are you willing to learn other skills? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Yes No This demonstrates RTs adaptability and should serve the profession well in the future. Do RTs View Themselves as Barriers? Staff Survey Are RTs themselves are barrier? No
Yes 0% 20% 40% 60% 80% Therapists do not view themselves as the barrier to protocols Staff Survey Conclusions Medical staff are perceived as the most significant barrier to protocols. Most RT staff do not view themselves as significant barriers Staff therapists do not view administrators and manager as significant barriers Nearly all RTs are willing to learn additional skills if adoption of protocols will assure that patients receive appropriate care A Note from the AARC Protocol
Implementation Committee Please use these slides in assessing potential barriers when implementing programs in your facility You should assess if the specific barriers at your hospital are different, so you can develop a successful strategy to overcome those barriers For additional information visit the Protocol Resources at www.aarc.org You can also contact the Chair of the Protocol Implementation Committee for a complete file of the Manager and Staff Surveys
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