Characteristics promoting behaviour change: physician experience with a coalition-led quality improvement initiative to reduce excessive laboratory test ordering

Abstract

BackgroundAttempts have been made to reduce excessive laboratory test ordering; however, the problem persists and barriers to physician involvement in quality improvement (QI) remain. We sought to understand physician participation experience following a laboratory test overuse initiative supported by a QI coalition.MethodsAs part of a larger mixed-methods study, structured virtual interviews were conducted with 12 physicians. The Theoretical Domains Framework (TDF) and the Behavioural Change Wheel (BCW) were used to identify characteristics that influence physician behaviour change for QI leadership and participation and appropriate blood urea nitrogen (BUN) test ordering. A content analysis of physicians’ statements to the TDF was performed, resulting in overarching themes; relevant TDF domains were mapped to the intervention functions of the BCW.ResultsNine overarching themes emerged from the data. Eight of 14 TDF domains influence QI leadership and participation, and 10 influence appropriate BUN-test ordering behaviours. The characteristics participants described that promoted a change in their QI participation, leadership and appropriate BUN-test ordering were: QI education with hands-on training; physician peer mentorship/support; personnel assistance (QI and analytics) and communication from a trusted/credible physician leader who shares data and insights about the physician role in the initiative, clinical best practice and past project success. Other elements included: a simply designed initiative requiring minimal effort and no clinical workflow disruptions; revised order forms/panels and limiting test-order frequency when laboratory tests are normal. Additionally, various future intervention strategies were identified. For their initial initiative participation, physicians acknowledged coalition leader or member credibility was more important than awareness of the coalition.ConclusionsBased on physicians’ described perceptions and experiences, coalition characteristics that influenced their QI leadership and participation, and appropriate BUN-test ordering behaviours were revealed; these characteristics aligned to several TDF domains. The findings suggest that these behaviours are multidimensional, requiring a multistrategy approach to change behaviour.

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“…Mather et al considered these the most important domains along with ‘skills’, ‘roles and responsibilities’ and ‘confidence in own ability’ [ 57 ]. This is supported by other reviews that have identified the most important domains for practice change being ‘environmental context and resources’, ‘social influence’, ‘knowledge’, ‘beliefs about ability’, and ‘beliefs about consequences’ [ 44 , 58 ]. While there is a great deal of convergence of finding from all studies there are some notable exceptions.…”

“…The importance of ‘social influence’ and ‘beliefs about capabilities’ across all studies emphasises the need to create opportunities for practitioner social support, coaching and building relationships. As Mathura found “relationships do matter, if you know somebody, and you trust them, it’s much more likely to do something that they are suggesting” [ 44 ].…”

Factors of a physician quality improvement leadership coalition that influence physician behaviour: a mixed methods study

“…Future intervention strategies were identified from the alignment to the BCW intervention functions41 (figure 2): ‘(1) communication from a local, credible physician to facilitate participation ; (2) provide past examples of physician-led projects targeting laboratory test reduction ; (3) provide laboratory test utilisation reports with cost data to demonstrate negative consequence ; (4) apply guidelines (laboratory test ordering protocols) ; (5) limit test order frequency when results are normal ; (6) update laboratory order forms/electronic order panels to reduce unnecessary test ordering ; (7) provide support personnel (eg, QI and data personnel ); (8) offer QI and clinical laboratory medicine educational sessions ; (9) provide hands-on QI opportunity to apply knowledge and leadership ; (10) physician role-modelling QI to aspire to or imitate ; and (11) offer incentives such as remuneration and formalise physician QI roles to encourage involvement ’. 43 pg. 5…”

“…Detailed reporting of the qualitative phase is published elsewhere. 43 From the interviews, 809 statements were coded into 13 TDF domains that resulted in 9 overarching themes: '(1) QI education and hands-on opportunities support involvement; (2) physician mentorship; (3) coalition functions as a safe peer-to-peer QI community; (4) trusted local physician leader sharing QI encourages participation; (5) provide initiative approach, data and physician role; (6) order BUN tests mindfully, not reflexively or habitually; (7) changing physician behaviour is difficult; (8) opportunity to lead, with support, a straightforward QI intervention that requires minimal effort; and (9) physician-led QI competed out'. 43 pg.…”