Richmond Austria 1998-08933 COMM 391 Unit II Assignment 1

Communicating Quality Improvement to Healthcare Professionals: Factors

Affecting Behavior towards Compliance with Regulatory Quality Indicators
By Richmond Austria
Overview of the Research Proposal:
Purpose of the research:
The purpose of this research is to develop an understanding of the factors that
influence behaviors of nurses, doctors and allied health staff using the theory of
planned behavior (TPB) towards their compliance with the implementation of quality
indicators set by the health regulator for a hospital in Abu Dhabi, UAE as
communicated to them by the management. As such, the theory of planned
behavior is one of the most widely utilized and researched theoretical frameworks
for explaining human behavior (McEachan et al., 2011). This will allow the
management to identify which predictors can be used as behavioral motivators and
improve the compliance of healthcare professionals with this regulatory requirement.
This will also present to the management some evidence-based recommendations
for the development of sub-programs that can influence healthcare professionals’
engagement using the most effective predictors for such behavioral compliance.
Explanation:
In Abu Dhabi, the Department of Health – Abu Dhabi, as the regulator of the
healthcare sector, is in the process of developing a robust and comprehensive new
quality framework. As part of this, they have selected some of the most important
indicators for hospital performance to be reported quarterly. Measuring these
indicators will help the health sector to establish a baseline of the quality provided
(DOH, 2014). The hospital management and quality department have engaged
healthcare professionals on this regulatory requirement and would therefore be
interested to identify behavioral predictors across compliance with this initiative and
work towards motivating them. Hence, the theory of planned behavior could be
used to understand how healthcare professionals behave upon implementation of
these quality indicators set by DOH as communicated to them by the management.
Proposed Variables and Prediction:
The independent variables include 12 constructs acting as predictors based from
the previous study of Wakefield et al. (2009) which could be:
1. Prior attendance to Quality Improvement Workshop
2. Work Satisfaction
3. Personal causes of errors
4. System causes of errors
5. Management responsiveness
6. Preventive action beliefs
7. Hospital and Quality Department support

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8. Incident analysis
9. Professional peer behavior
10. Behavioral norms
11. Belief in the paradigm of quality
12. Belief in the paradigm of open disclosure
The dependent variable will be a composite of the 5 behavioral DOH compliance
constructs measured on 10-point Likert scale which will include:
1. Level of awareness on DOH indicators
2. I follow hospital clinical guidelines that relate to DOH indicators
3. I coordinate with quality department and the management especially for
issues related to DOH indicators
4. I communicate difficulties to colleagues related to compliance to DOH
indicators
5. I support the management for changes that are necessary for compliance to
DOH indicators
Proposed Statistical Analysis:
The TPB model will test 12 constructs to identify significant predictors of
high-level of DOH quality indicator compliance using the SPSS software. The
continuous outcome variable, the DOH behavioral compliance score, will be
reclassified into high (responses of ≥6) and low (<6) as based from the method of
Wakefield et al. (2009). The proportions of clinicians with high-level of DOH
behavioral compliance score will be examined, and ORs for each of the clinical
groups will be compared against the clinical group with the lowest score. A single
model for all clinicians, and individual models for each of the 3 clinical subgroups
(physicians, nurses, allied health) will be developed.
The 12 independent variables will be entered into a backward (non-conditional)
stepwise multiple logistic regression model to identify significant predictors of
high-level of DOH quality indicator behavioral compliance. Alpha will be set at the
5% level. To compare the crude ORs of each significant predictor, by the amount of
improvement in high-level of DOH quality indicator compliance that could be
achieved for every one-unit improvement along the Likert-type scale, the beta
coefficient will be adjusted for the interquartile range of each predictor. Adjusted
ORs (AORs) in the final model will be calculated by multiplying the beta coefficients
by the interquartile range of the scale. The AORs will be equivalent to crude ORs
where the interquartile range was one as based from the method of Wakefield et al.
(2009).
Research Design:
The research design that will be used is correlational as based from the notation
of Campbell and Stanley (1963). Such a correlational study measures two variables
and assesses their statistical relationship. In this case, the TPB model will test 12

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constructs to identify significant predictors for high-level of DOH quality indicator

behavioral compliance among healthcare professionals.
The Research Gap:
The Theory of Planned Behavior suggests that an individual's behavior is
determined by his/her intention to perform that behavior. The strength of the
intention is directly influenced by three variables. This includes attitude towards the
behavior, such as an individual's beliefs about the consequences of the behavior and
how much they value those consequences. This is exemplified by "I think
implementing research findings in my clinical work is important because my patients
will benefit". Another one is the Subjective norm about the behavior which refers to
an individual's beliefs about how their peers or important people (known as
referents) will view the behavior in question and how much the individual wishes to
gain approval from these people. This is exemplified by "My supervisor expects me
to critique that journal article and present it at the multidisciplinary team meeting”.
Lastly, the Perceived behavioral control regarding the behavior which refers to an
individual's perception of his/her ability to perform a given behavior and how much
control they have over the change. This is exemplified by "I know how to critique
that article and I'm sure I can apply the findings to my practice (McEachan et al.,
2011).
The theory of planned behavior (TPB) is a well-validated behavioral
decision-making model that has been used to predict social and health behaviors.
This was used by Javadi et al. (2013) in their study of nurses which revealed that
“normative beliefs” had the greatest influence on nurse’s intention to implement
patient safety behaviors.
In the study conducted by Wakefield et al. (2010), TPB was used to develop
behavioral models for high-level Patient Safety Behavioral Intent (PSBI) of senior and
junior doctors, senior and junior nurses, and allied health professionals. Their
research used multiple logistic regression analysis to identify factors that significantly
influenced PSBI between the five professional groups. Moreover, professional
peer-modelling behaviors and individuals’ beliefs about the value of those behaviors
in improving patient safety are important predictors of healthcare workers’ patient
safety behavior.
The research of Klaic et al. (2019) showed that allied health professionals have
positive attitudes towards Evidence Based Practice (EBP) but low normative beliefs
and low perceived behavioral control. Organization-specific factors outside the
control of the participants were found to have the greatest impact on intention to
participate in EBP.
The study of Audet et al. (2005) showed that physicians do not routinely use
data for assessing their performance and are reluctant to share those data. They
infrequently participate in redesign activities. However, physicians in larger and
salaried groups are more likely to be engaged in quality improvement.

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While TPB has been successfully applied in many key public health interventions,
it remains greatly underutilized in healthcare quality improvement. Understanding
and applying such methodologies to quality improvement could potentially provide
better health outcomes especially for regulatory requirements that are being
communicated by the management for healthcare workers to follow.
Conceptual and Operational Definitions:
1. Quality: the degree to which health services for individuals and populations
increase the likelihood of desired health outcomes and are consistent with
current professional knowledge (Mainz, 2003).
2. Indicators: quantitative measures that can be used to monitor and evaluate
the quality of important governance, management, clinical, and support
functions that affect patient outcomes (Mainz, 2003).
3. Prior attendance to Quality Improvement Workshop: refers to receiving and
attending a quality improvement workshop related to basic concepts of
quality and regulatory requirements as organized by the hospital
management
4. Work Satisfaction: refers to the perceptions about satisfaction with the job
(Wakefield et al., 2009).
5. Personal causes of errors: belief in causes such as stress, fatigue and other
avoidable causes (Wakefield et al., 2009).
6. System causes of errors: belief in the impact of workplace/environment on
patient safety, staffing levels, skills, space, equipment, resources (Wakefield
et al., 2009).
7. Management responsiveness: perceptions about management providing
feedback and not blaming staff for incidents (Wakefield et al., 2009).
8. Preventive action beliefs: an individual’s belief about whether engaging in
specific patient safety-related behaviors improve patient safety (Wakefield et
al., 2009).
9. Hospital and Quality Department support: perception of support for patient
safety such as providing staff education, mentoring, orientation,
undergraduate patient safety education (Wakefield et al., 2009).
10. Incident analysis: belief that management use information to inform and
prevent further incidents (Wakefield et al., 2009).
11. Professional peer behavior: perceptions about one’s own professional
colleagues’ patient safety behavior (Wakefield et al., 2009).
12. Behavioral norms: perceptions about the behavior of all clinicians’ patient
safety behavior (Wakefield et al., 2009).
13. Belief in the paradigm of quality: belief in human factors engineering the
principles of standardization, redundancy, forcing functions, systems redesign,
etc. (Wakefield et al., 2009).
14. Belief in the paradigm of open disclosure: belief in whether being open and
honest with patients/family after an adverse event contributes to improved
patient safety (Wakefield et al., 2009).

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References:
Audet, A.M., Doty, M.M., Shamasdin, J. and Schoembaum, S.C. (2005).
Measure,Learn and Improve: Physicians' Involvement in Quality
Improvement.HealthAffairs Available from:
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.24.3.843
Campbell, D.T. and Stanley, J.C. (1963). Exeprimental and Quasi-experimental
Designs for Research. Available from:
https://www.sfu.ca/~palys/Campbell&Stanley-1959-Exptl&QuasiExptlDesignsFor
Research.pdf
DOH (2014). JAWDA- Quality Metrics. Available from:
https://www.haad.ae/haad/tabid/1489/Default.aspx
Javadi, M., Kadkhodaee, M., Yaghoubi, M., Maroufi, M., & Shams, A. (2013). Applying
theory of planned behavior in predicting of patient safety behaviors of nurses.
Materia socio-medica, 25(1), 52–55. doi:10.5455/msm.2013.25.52-55\
Klaic, Marlena ; McDermott, Fiona; Haines, Terry. (2019). Does the Theory of
Planned Behaviour Explain Allied Health Professionals' Evidence-Based Practice
Behaviours? A Focus Group Study. Journal of Allied Health; Washington Vol. 48,
Iss. 1, (Spring 2019): E43-E51.
Mainz, J. (2003). Defining and classifying clinical indicators for quality improvement,
International Journal for Quality in Health Care, Volume 15, Issue 6, Pages 523–
530, https://doi.org/10.1093/intqhc/mzg081
McEachan RR, Conner M, Taylor NJ, Lawton RJ. (2011). Prospective prediction of
health-related behaviours with the theory of planned behaviour: a meta-analysis.
Health Psychol Rev.;5(2):97-144.
Wakefield, John G ; McLaws, Mary-Louise ; Whitby, Michael ; Patton, Leanne (2010).
Patient safety culture: factors that influence clinician involvement in patient
safety behaviours. Quality & Safety in Health Care; London Vol. 19, Iss. 6, (Dec
2010): 585. DOI:10.1136/qshc.2008.030700

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