IDENTIFYING AND OVERCOMING BARRIERS TO IMPLEMENTATION OF SHARED DECISION MAKING AND DECISION AIDS

Purpose:   The purpose of the study is to identify and overcome barriers to implementation of shared decision making and patient decision aids in three multispecialty fee-for-service systems in western Washington State.

Method:   Four methods are used to identify barriers and strategies to overcome them: 1) key informant interviews with clinical and operational staff using open-ended response prompts; 2) monthly collaborative meetings with partners from the implementation sites; 3) monthly conference calls with a network of 11 shared decision making demonstration sites across the United States; and 4) synthesis and dissemination of relevant peer-reviewed journal articles, popular press articles, and state and federal legislation.

Result:   Barriers to implementation vary significantly in each of the three implementation sites.  Factors include the capabilities of the sites’ electronic health record systems, patient volume, availability of support staff, wait time for appointments, the nature of the health conditions selected for decision aid support (preference-sensitive care, chronic conditions, or screening tests), institutional review board process, and competing priorities within the system.  There are several successful strategies to overcome identified barriers.  One key step is to identify clinical and administrative champions early in the process.  Implementation is facilitated by aligning shared decision making with other initiatives and embedding it in strategic and organizational goals.  Decision aid distribution workflow maps should be reviewed and revised a couple of months after implementation, and periodically on an ongoing basis.  Workflow maps should include a way of feeding data back to providers.  Having dedicated care coordinators or health coaches helps in overcoming logistical barriers and in closing the loop with patients.  A communication toolkit with sample templates to explain shared decision making to providers, staff, and patients can be useful.  Finally, it is helpful to be part of a network of sites implementing shared decision making and decision aids in order to share strategies for overcoming obstacles.

Conclusion:   Shared decision making can be implemented in a multispecialty fee-for-service system.  Barriers to implementation can be overcome with engaged champions, operational planning, and communication with a network of other implementation sites.