title: Addressing the sociotechnical drivers of quality improvement: a case study of post-operative DVT prophylaxis computerised decision support.
abstract: BACKGROUND
  Quality improvement (QI) initiatives characterised by iterative cycles of quantitative data analysis do not readily explain the organisational determinants of change. However, the integration of sociotechnical theory can inform more effective strategies. Our specific aims were to (1) describe a computerised decision support intervention intended to improve adherence with deep venous thrombosis (DVT) prophylaxis recommendations; and (2) show how sociotechnical theory expressed in 'Fit between Individuals, Task and Technology' framework (FITT) can identify and clarify the facilitators and barriers to QI work.
  
  
  METHODS
  A multidisciplinary team developed and implemented electronic menus with DVT prophylaxis recommendations. Stakeholders were interviewed and human factors were analysed to optimise integration. Menu exposure, order placement and clinical performance were measured. Vista tool extraction and chart review were used. Performance compliance pre-implementation was 77%.
  
  
  RESULTS
  There were 80-110 eligible cases per month. Initial menu use rate was 20%. After barriers were classified and addressed using the FITT framework, use improved 50% to 90%. Tasks, users and technology issues in the FITT model and their interfaces were identified and addressed. Workflow styles, concerns about validity of guidelines, cycle times and perceived ambiguity of risk were issues identified.
  
  
  CONCLUSIONS
  DVT prophylaxis in a surgical setting is fraught with socio-political agendas, cognitive dissonance and misaligned expectations. These must be sought and articulated if organisations are to respond to internal resistance to change. This case study demonstrates that QI teams using information technology must understand the clinical context, even in mature electronic health record environments, in order to implement sustainable systems.
authors.affiliation: Portland Oregon VA Medical Center, Oregon Health and Sciences University, Portland, Oregon, USA. blake.lesselroth@va.gov
authors.forename: Blake J
authors.initials: BJ
authors.lastname: Lesselroth
authors.forename: Jianji
authors.initials: J
authors.lastname: Yang
authors.forename: Judy
authors.initials: J
authors.lastname: McConnachie
authors.forename: Thomas
authors.initials: T
authors.lastname: Brenk
authors.forename: Lisa
authors.initials: L
authors.lastname: Winterbottom
mesh_terms: D020000:Decision Support Systems, Clinical; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D011182:Postoperative Care / Q000592:standards*; D017410:Practice Guidelines as Topic; D058996:Quality Improvement; D020246:Venous Thrombosis / Q000517:prevention & control*