Theory-based identification of barriers to quality improvement: induced abortion care.
BACKGROUND
The UK Royal College of Obstetricians and Gynaecologists published the clinical guideline, The Care of Women Requesting Induced Abortion, to address recognized variations in care. There is little empirical evidence on factors that influence compliance with the guideline. A better understanding of such factors is needed for quality improvement initiatives.


OBJECTIVE
To identify factors that influence compliance with two key guideline recommendations: offer of an assessment appointment within 5 days of referral, and supply of contraceptives at discharge.


METHODS
Thirteen hospital gynaecology units in Scotland.


METHODS
Guideline compliance was measured by a case note review. Barriers and facilitators were identified using a combination of approaches: semi-structured interviews with local gynaecologists and a survey of clinical staff. The questionnaire, based upon constructs from the Theory of Planned Behaviour, measured behavioural intention, attitude, subjective norm (perceived social pressure), and perceived behavioural control.


RESULTS
Of 507 cases reviewed, median unit compliance was 46% for the assessment appointment and 59% for contraceptive supplies. Questionnaires were returned by 151 (74%) of 205 staff in 12 units. The interviews and open-ended questions highlighted organizational barriers to guideline implementation. Staff generally had strong intentions and positive attitudes to follow both recommendations. For the assessment appointment, perceived behavioural control was low. The Theory of Planned Behaviour accounted for 27% of the variation in intentions, with subjective norm being the strongest predictor. Intention and perceived behavioural control best explained unit compliance, together explaining 15% of the variation. For contraceptive supplies, the theory accounted for 34% of the variation in intentions, with perceived behavioural control being the strongest predictor.


CONCLUSIONS
Clinical staff were highly motivated to implement the guideline but hindered by organizational constraints. Quality improvement initiatives need to target organizational barriers as well as individual professionals.
Foy
Robbie
R
Scottish Programme for Clinical Effectiveness in Reproductive Health, University of Edinburgh, Edinburgh, Scotland, UK. r.c.foy@ncl.ac.uk
Walker
Anne
A
Ramsay
Craig
C
Penney
Gillian
G
Grimshaw
Jeremy
J
Francis
Jillian
J
D000028:Abortion, Induced / Q000592:standards*; D001071:Appointments and Schedules; D001291:Attitude of Health Personnel; D003271:Contraceptive Agents, Female / Q000600:supply & distribution; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D033182:Intention; D007407:Interviews as Topic; D008485:Medical Audit / Q000706:statistics & numerical data*; D008505:Medical Staff, Hospital / Q000523:psychology / Q000592:standards*; D009775:Obstetrics and Gynecology Department, Hospital / Q000458:organization & administration / Q000592:standards*; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care; D012017:Referral and Consultation / Q000592:standards; D012606:Scotland; D011795:Surveys and Questionnaires; D016526:Workload
D003271:Contraceptive Agents, Female