Table 5 Barriers and facilitators of CPG use
Themes | Quotes on perceived effective implementation strategies |
|---|---|
Barriers | |
Insurance coverage of services | ‘Insurance does not cover the drug’ |
Competition of private sector | ‘Continuity of care, the private clinics does not have guidelines’ |
Patient-related | ‘Patients’ acceptance’ ‘They don’t like to break their fast on Ramadan days’ ‘The taste of the oral solution’ ‘A lot reject the test’/‘They vomit’ ‘1 in 4 will accept’ |
Doctor-related | ‘Patients are not coming’ ‘Asthma action plan is devised by the chest physician’ ‘It (asthma action plan) will take time from doctors’ ‘Doctors believe and practice’ ‘Doctors are interested; we are checking the KPI and commenting on how to improve the practice’ |
Communication between hospitals and AHS | ‘It is followed in the hospital’ |
Lack of structured care for some conditions (e.g., asthma and osteoporosis) compared to widely implemented structured care for diabetes and hypertension in the AHS | ‘You have to choose the ones who are interested. You should not choose all. Doctors who don’t care shouldn’t be in the institution’ ‘Most have their spirometer but some clinics don’t’ ‘Accessing the whole organization and not individuals’ ‘It differs if you have a chronic disease care clinic. Doctors will be under pressure by other patients and will not give good care, and some doctors don’t have a sense of responsibility’ ‘There are no guidelines for osteoporosis’ ‘No, it is not like diabetes mellitus (DM); there are no guidelines and no special clinics’ ‘We are not following our target patients (osteoporosis patients)’ ‘It is a mistake of the institutions to not recommended screening for adults’ ‘Having well women clinics is better than having GP clinics’ |
Condition-related | ‘There is a higher prevalence of DM, complications, and diagnosis’, ‘easier to diagnose DM’, ‘all age groups have DM’ |
Facilitators | |
Accessibility of knowledge in the office | ‘Makes things easier; so, if you have any questions you have the answer easily’ ‘It reduces the anxiety of feeling alone, especially during out-of-hours clinics’ ‘Calculators are available in computers and programmes’ |
Quality monitoring | ‘Auditing’ ‘Institutional KPI’ ‘Patient satisfaction KPI’ ‘Guidelines improve their KPI; it should support the KPI or targets’, ‘They are seeking the KPI level four times per year’ ‘Other types of auditing, which we don’t know about in hospitals, like how our care affects admissions, complicated patients, and compliance’ ‘Yes, now they are trying their best to better achieve the KPI’ ‘To reach the KPI and help patients’ |
Endorsement from the institution | ‘They formulated guidelines but didn’t work to improve implementation of guidelines…it is individual work’ ‘If the guidelines are available in the institution, it is the responsibility of all to follow it because we all care for the same patients and we should speak the same language with the patient’ ‘About breast cancer screening; it is a national programme. They didn’t give the option to do it or not. So, we are applying it and until they change it I have to follow it as it is supported by the organization’ ‘We cannot follow the institution always; this depends on the situation because if what is recommended by the institution is wrong we might miss-practice and put the patient at risk’ ‘As long as the guidelines are issued by the organization it is more likely to be followed and more likely that they have something in their mind; we are not aware of all statistics they have. They have all statistics and information, and as long as it is not harmful we follow them’ ‘The HAAD and SEHA are looking for quality now’ |
Electronic medical records | ‘It is difficult with paper medical records and needs staff’ ‘Introduction to m-pages (health maintenance reminder page) is one way of helping people to follow the guidelines’ ‘If it used, it is effective’, ‘guidelines link to medical records’ |
Structured care | ‘It differs if you have a Chronic Diseases Clinic from if you don’t, and doctor will be pushed by other patients and will not provide good care. Some doctors don’t have a sense of responsibility’ ‘If not, Chronic Diseases Clinic performance will be the same? I don’t think [so] at all’ ‘If I was a GP and a chronic disease patient visited me, I will not be able to attend to him well, because many more patients will be waiting outside’ |