Exploring Policy Change in the Emergency Department: A Qualitative Approach to Understanding Local Policy Creation and the Barriers to Implementing Change

Abstract

IntroductionWith thousands of new medical trials released every year, health care policymakers must work diligently to incorporate new evidence into clinical practice.Although there are some broad conceptual frameworks for knowledge translation in the emergency department (ED), there are few user-centered studies that illustrate how local policymakers develop and disseminate new policies.ObjectivesOur study sought to evaluate the process by which new departmental policies are formed in ED, how new evidence was integrated into this process, and to explore barriers to implementation.MethodsSemi-structured interviews were conducted with local administrators from nine major hospitals in Ontario, Canada. Interviews were transcribed and qualitative data was analyzed using constructivist grounded theory.ResultsFive broad steps in the policy creation process were identified: 1) Problem identification and motivation for change; 2) building a policy team; 3) policy construction; 4) implementation and monitoring of new departmental policies; 5) actively addressing barriers to the ED policymaking process. Common sub-themes in each of these categories were highlighted. Four main themes also emerged regarding barriers experienced in policymaking: Education and knowledge transfer; lack of a change culture; resource limitations; and cumbersome bureaucratic structures.ConclusionOur study identified common facilitators and barriers that policymakers face in their ability to create health policy in the ED. While local context influences the policymaking process, a standardized framework would ensure a more systematic approach for policymakers and allow scientists to better understand how evidence is integrated at the local level.

A qualitative evidence synthesis (QES) exploring the barriers and facilitators to screening in emergency departments using the theoretical domains framework

“…Furthermore, access to memory aids such as algorithms and simple protocols developed with staff and monitoring adherence of new screening practices through staff assessment helped to resolve these knowledge deficits. Similar to Shaikh et al (2018) [ 30 ], a lack of willingness to change practices within the ED was also a barrier with a lack of time to update knowledge and skills described as a consistent challenge.…”

“…Resource limitations, a lack of culture change and cumbersome bureaucratic structures are well recognised as barriers to implementing change and understanding local policy creation in the ED (Shaikh et al, 2018 [ 30 ]). This synthesis further identified screening specific barriers to knowledge and skills development with staff finding screening protocols difficult to recall, particularly in a busy ED environment where constant updates complicated the process and were difficult to adhere too.…”

“…Successful implementation requires monitoring of new departmental policies, required infrastructure and teamwork (Shaikh et al, 2018 [ 30 ]). Similarly, this synthesis found that ready access to resources that would underpin screening were considered vital, particularly with what was considered to be more complex forms of screening, sepsis being a prime example.…”

Lessons learned about policymaking: Moving an emergency department–initiated screening protocol to systemwide input in the development and implementation process

“…To our knowledge, there is no clear consensus on what the optimal process of policy creation is for an ED, due to unique environment at each institution. Shaikh et al 9 have identified five steps in policymaking process in the ED, starting with identification of the problem, creating a policy team, constructing the policy, implementing, and monitoring it and actively addressing barriers to ED policymaking throughout the process.…”