NU813 Unit 4 Barrier Analysis Example

Done but Not Counted: A Barrier Analysis of Foot Exams Recorded in Free Text From Week 3 to Week 6 at a Composite Community Health Center, the 41 Patients Called Back for an Exam They Already Had, and the Fix

[Student Name]

Purdue University Global

NU813: DNP Project Implementation

Unit 4 Barrier Analysis

[Instructor Name]

[Date]

The health center, systems and figures are composite; counts and weeks are bracketed.

The Barrier

The foot exam flowsheet was placed in the rooming navigator for the main clinic's regular medical assistant profile. Float assistants, who cover absences at both clinics, use a different profile, and the flowsheet did not appear in their navigator. Wanting to document the exams they had done, they recorded them in the free-text rooming note, often in detail. The exams were real and generally complete. But the care-gap report reads only the flowsheet, so those patients' gaps stayed open.

How It Was Found

The barrier was found in [week 5], when the nurse educator compared her observation log with the flowsheet data and found [three] exams she had watched that did not appear in the report. A chart search for foot exam terms in free-text notes from launch onward then found [41] exams, all recorded by float assistants.

How Long It Lasted and Whom It Affected

The barrier lasted from launch in [week 3] until the fix in [week 6], about three and a half weeks. During that time float assistants roomed about one patient in five. The [41] uncounted exams represented roughly [16] percent of all exams done at the main clinic in that period, so the project's reported coverage was understated by about that amount.

The harm was not only to the data. The health center's outreach team works from the same care-gap report, and during those weeks it sent reminder letters and made calls to patients with open foot-exam gaps. [Twenty-six] of the [41] patients were contacted, and [9] came back for a visit to have an exam they had already received. One patient told the front desk she had "just had her feet checked."

The exam was done, the patient was helped, and the system still told her she was overdue, because it could not read what the assistant wrote.

Why It Happened

Three factors combined. The build was tested only under the regular assistant profile. Float assistants were not in the original training plan, as the status report had noted, so no one showed them where the flowsheet should be. And the free-text note, being always available, offered an easy alternative that looked like documentation. An implementation framework would place this in the inner setting, among the structures and information systems of the organization, rather than in the individuals involved (Damschroder et al., 2009); the assistants did what the system let them do.

The Fix

In [week 6], informatics added the flowsheet to every rooming profile at both clinics, and the free-text rooming note was given a prompt directing users to the flowsheet when they type foot-related terms. The [41] exams found in free text were entered into the flowsheet by the nurse educator, closing the gaps, and outreach was paused for those patients. Float assistants received the same training as others.

Options Considered

Two other responses were considered and set aside. Retraining float assistants alone would have fixed the problem only as long as the same assistants stayed, and would not have helped the next person using that profile. Removing the free-text rooming note would have stopped the workaround, but the note is used for many other purposes, and taking it away would have created new problems. Changing the build addressed the cause for every future user.

What the Barrier Cost

The [nine] unnecessary visits each took a scheduled appointment slot of [20] minutes, about three hours of clinic time in total, and each patient lost time and, for several, a bus fare. Outreach staff spent an estimated [five] hours calling patients whose gaps were already closed in fact. Those costs are small in money but real for the patients, and they would have grown every week the barrier continued.

Effect on Fidelity Measures

Carroll and colleagues' framework distinguishes adherence, whether the intervention was delivered, from how it is recorded (Carroll et al., 2007). Here, adherence was higher than the data showed; the barrier was in measurement, not delivery. Coverage for weeks three to six has been recalculated with the recovered exams, and reports now show both the original and corrected figures, labeled.

What It Teaches

Two lessons carry beyond this project. First, a build should be tested under every user profile that will touch it, not only the main one. Second, a measure that drives outreach can cause harm when it is wrong, so errors in a care-gap report deserve the same urgency as clinical errors. Implementation research treats fidelity and adoption as outcomes to be measured, but measuring them depends on data systems that capture what staff actually do (Proctor et al., 2011).

References

Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, Article 40. https://doi.org/10.1186/1748-5908-2-40

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. https://doi.org/10.1186/1748-5908-4-50

Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., Griffey, R., & Hensley, M. (2011). Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Administration and Policy in Mental Health and Mental Health Services Research, 38(2), 65-76. https://doi.org/10.1007/s10488-010-0319-7