Why aren't we achieving our goals?
 
This is about…
Understanding gaps between current and recommended practice
Applicable to level(s)
Single practice      
Network of practices       
Regional or national networks
Likely skills and resources needed
Clinical      Administrative      Management
Likely difficulty
Likely time commitment
Do…
Consider the range of individual, team and organisational level factors that can influence clinical care
Focus on identifying the most important factors that you can change
Don’t…
Assume that lack of knowledge is the main explanation for evidence-practice gaps
Illustrations
From research studies:
A qualitative study to understand adherence to multiple evidence-based indicators in primary care.
A qualitative study to understand long-term opioid prescribing for non-cancer pain in primary care.
A systematic review of barriers to effective management of type 2 diabetes in primary care.
Helpful resources
There are many frameworks which set out various ways of grouping factors that influence practice. Some are rather detailed but this sample illustrates a range of approaches.
A checklist for identifying determinants of practice (see Table 1).
 
 
Barriers and enablers
Every clinician and manager knows that changing clinical practice is seldom easy. Change generally takes time, effort and supporting resources. In planning change, you may find it useful to identify and think about barriers to and enablers of change. Then you can consider which of these are important and are feasible to address, or too difficult within limited time and resources. You may decide that the effort-reward ratio is too unfavourable to prioritise a given change and therefore choose to tackle a different priority. (Luckily, there is no shortage of priorities to address in primary care.)
 
Frameworks to help understand behaviour and guide behaviour change
Frameworks can act as prompts to identify influences on clinical practice. They can help you consider factors that you might otherwise not have thought of. There is quite a variety of frameworks and they all tend to overlap. There is no evidence that one framework is any better than another. The choice largely comes down to whichever you find easiest or most intuitive to use.
 
Table 1 is adapted from an interview study of primary care staff, which used one framework to understand barriers to and enablers of adherence to a set of evidence-based indicators.7 The Theoretical Domains Framework is useful because it focuses on beliefs, attitudes and so forth that you can potentially change.8
 
Table 1. Influences on the achievement of four indicators, categorised using the Theoretical Domains Framework.7
 
Methods to explore barriers and enablers
There are a number of ways to influences on practice. How intensive this needs to be inevitably depends on judgment and resources available. For example, you may already have a good working knowledge of factors that influence the care of common clinical priorities, such as diabetes or hypertension. However, you might still find it useful to set out the most important enablers of and barriers to recommended practice before deciding what action to take. The key is to ensure that those targeted by any planned change are involved and agree upon the main barriers and enablers. Table 2 summarises some approaches you could consider.
 
Table 2. Methods of exploring barriers and enablers.
 
Making sense of barriers and enablers
Consider prioritising for action:
  • Those which are most important, e.g. frequently encountered, pivotal steps in patient pathways
  • Those with strongest consensus amongst team members
  • Those most amenable to change, e.g. staff beliefs and processes of care as opposed to structures and wider environmental factors
  • Those which can be readily linked to one or more approaches to change practice