Abstract
BackgroundImplementation of clinical practice guidelines into daily care is hampered by a variety of barriers related to professional knowledge and collaboration in teams and organizations. To improve guideline concordance by changing the clinical decision-making behavior of professionals, computerized decision support (CDS) has been shown to be one of the most effective instruments. However, to address barriers at the organizational level, additional interventions are needed. Continuous monitoring and systematic improvement of quality are increasingly used to achieve change at this level in complex health care systems. The study aims to assess the effectiveness of a web-based quality improvement (QI) system with indicator-based performance feedback and educational outreach visits to overcome organizational barriers for guideline concordance in multidisciplinary teams in the field of cardiac rehabilitation (CR).MethodsA multicenter cluster-randomized trial with a balanced incomplete block design will be conducted in 18 Dutch CR clinics using an electronic patient record with CDS at the point of care. The intervention consists of (i) periodic performance feedback on quality indicators for CR and (ii) educational outreach visits to support local multidisciplinary QI teams focussing on systematically improving the care they provide. The intervention is supported by a web-based system which provides an overview of the feedback and facilitates development and monitoring of local QI plans. The primary outcome will be concordance to national CR guidelines with respect to the CR needs assessment and therapy indication procedure. Secondary outcomes are changes in performance of CR clinics as measured by structure, process and outcome indicators, and changes in practice variation on these indicators. We will also conduct a qualitative process evaluation (concept-mapping methodology) to assess experiences from participating CR clinics and to gain insight into factors which influence the implementation of the intervention.DiscussionTo our knowledge, this will be the first study to evaluate the effect of providing performance feedback with a web-based system that incorporates underlying QI concepts. The results may contribute to improving CR in the Netherlands, increasing knowledge on facilitators of guideline implementation in multidisciplinary health care teams and identifying success factors of multifaceted feedback interventions.Trial registrationNTR3251.
Highlights
Implementation of clinical practice guidelines into daily care is hampered by a variety of barriers related to professional knowledge and collaboration in teams and organizations
This paper describes the design of an evaluation study of a multifaceted intervention combining indicator-based performance feedback and educational outreach visits to improve guideline implementation in a context of multidisciplinary cardiac rehabilitation (CR) teams working with an electronic patient record (EPR) with computerized decision support (CDS) already
Intervention We will carry out a multifaceted guideline implementation intervention that consists of two elements: (i) quarterly feedback on quality indicators for CR, provided as part of a web-based quality improvement (QI) system and (ii) educational outreach visits using the same system to set up a QI plan together with a local QI team
Summary
Study design The effect of the intervention will be evaluated in a multicenter cluster-randomized study with a balanced (2 × 2) incomplete block design. Cluster-randomization is chosen to avoid contamination among professionals within the same clinic [25]. Clinics will be divided into two study arms (A and B).
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