Common Barriers and Challenges
While we are all convinced that SBIRT is THE public health response to hazardous substance use, all organizations implementing it run into barriers.
Here is a short list of problems you may encounter (because we did), and how we and others have overcome them. It goes without saying that the list is incomplete!
- “We don’t have time!” Most commonly these relate to clinic overload, and the dismay at “one more preventive health activity I have to deal with”. This is the biggest barrier to implementation we have learned about in questioning our staff and residents.
- “These aren’t reasonable procedures or guidelines.” Some physicians and staff may privately question “are these prudent limits realistic”. This attitude may reflect the physicians’ and staff’s own drinking patterns, and their reluctance to accept the implication that they may be drinking at hazardous levels. Generally, this is worth addressing directly in the initial buy-in process (i.e., by saying that as these programs are started, it is important for the staff to reflect on their own drinking patterns).
- “This screening thing isn’t a valid thing for me to be doing.” We have learned that the cultural backgrounds of the physician may alter the acceptance of screening as a valid medical activity for a physician. This may result from a broader lack of appreciation for the psychosocial model of disease. It may also reflect differing cultural norms related to whether any drinking is acceptable or if it is polite to question patients about their use of alcohol.
- “We can’t manage the data.” Managing the screening data and the results of interventions. Commercial EMRs may not have modules for these data. We have found that the physicians may review the screening questions and provide interventions, but not document this. It may be possible to make this easier through the design of the EMR (e.g., making the screening results have as high a visibility as vital signs in the encounter sheet: this will of course be very system-dependent).
- “Its going to be too much work.” The changes in work flow described in this module, the need to capture the results of screening and track results, the need to engage the physicians and residents and screening will all require sustained support from the implementation team and from those in positions of authority who support the effort.
- “There’s too much involved in changing our workflow.” The moving target concern related to simultaneous redesign of work flow, physical layout of clinic (or a move to another venue), and changes in the EHR.
- Lack of directives or organizational authority. This really affects all the above. In a large organization, the importance of having someone higher up in authority buy in to the project cannot be overstated. You either need one person for who has ultimate authority over everyone who will be affected OR you need the buy in of multiple authorities. Clinic managers, when dealing with a broader structure like a large medical organization, may have insufficient authority to really make SBIRT work as they may receive pushback from those under the authority of others (i.e., medical chart workers or physicians, neither of whom report to the clinic manager). There were several areas in our own project wherein, had we not had the weight of a senior authority behind us, we would potentially have lost months of time.
If you can address these in planning, and keep them in mind as you seek buy in and launch the effort, you will be far more likely to be successful than otherwise. Moreover, just being aware of them may help you, and your team, sustain themselves through adversity as you encounter them.
Because knowing what bad things may get in the way, goes a long way toward being able to handle them if and when the do occur!