Top 10 Pitfalls to Implementing a Protocol in Your Hospital and How to Avoid Them

Dr. Sparks

Presenters: Raymond Lejano, MD, Ha Nguyen, MD, and Pete Van Hoff, MD

A hospital protocol is a mandatory, specific set of decision-making processes or standards based on best practices. Protocols are important in promoting safe, efficient, consistent, and high-quality care while maintaining space for future improvement. Protocols are made through a generally universal set of stages including literature review, drafting, feedback and approval, implementation, monitoring, and adjustments. These are the 10 most common pitfalls to implementing a new protocol and how to avoid or resolve them:

1. Not being clear or concise enough when drafting the protocol. Avoid this pitfall by reviewing the scope during the writing stage.
2. Delayed feedback for the new protocol. Avoid this pitfall by identifying key shareholders early and setting clear deadlines for review or feedback, with frequent follow-up.
3. Delayed committee or departmental approval. Avoid this pitfall by confirming protocol approvers and meeting frequencies.
4. Lack of consensus on best practices among shareholders. Avoid this pitfall by identifying the “whys” surrounding the disagreement and reviewing relevant literature; consider making a clearly delineated exception to the protocol if a disagreement persists.
5. The protocol doesn’t align with your electronic health records (EHR) or resources. Avoid this pitfall by identifying an information technology liaison early and determining whether the protocol requires a third-party tool that may not be immediately compatible with your EHR.
6. Delayed EHR changes. Avoid this pitfall by staying in close contact with the information technology team and using flexible language so that the protocol can go live despite unanticipated EHR delays.
7. Unclear education of staff on the new protocol. Avoid this pitfall by including the reasoning for the practice change, assigning physician liaisons for different units, making the protocol easily accessible, and removing old or outdated policies.
8. Challenges in the maintenance of staff education. Avoid this pitfall through the use of pre-recorded education, online modules, and reminders at important department or unit meetings.
9. Inconsistent practice after the launch of the new protocol. Avoid this pitfall with an intentional emphasis on education, newsletters, and reminders at department meetings; consider tracking discrepancies for quality improvement.
10. Blind spots or unintended outcomes. Avoid or resolve this pitfall with close monitoring and review of process measures, making adjustments as needed.

Key Takeaways

• Creating hospital protocols can standardize and improve patient care.
• The most common pitfalls in protocol implementation involve timeline delays, education, and EHR logistics.
• It’s important to be forward-thinking in drafting new protocols to best anticipate the most common pitfalls and how to avoid them

Dr. Sparks is a pediatric hospitalist at Norton Children’s Hospital and an assistant professor of pediatrics at the University of Louisville School of Medicine, both in Louisville, Ky.