BMJ Qual Saf 20:381-389 doi:10.1136/bmjqs.2010.042689
  • Original research

Addressing the sociotechnical drivers of quality improvement: a case study of post-operative DVT prophylaxis computerised decision support

Open Access
  1. Lisa Winterbottom1
  1. 1Portland Oregon VA Medical Center, Oregon Health and Sciences University, Portland, Oregon, USA
  2. 2Portland Oregon VA Medical Center, Portland, Oregon, USA
  1. Correspondence to Blake J Lesselroth, Portland Center for Evaluation of Clinical Services, P3 MED, Portland Veterans Affairs Medical Center, 3710 Southwest US Veterans Hospital Drive, Portland, Oregon, USA; blake.lesselroth{at}
  • Accepted 15 August 2010
  • Published Online First 5 January 2011


Background Quality improvement (QI) initiatives characterised by iterative cycles of quantitative data analysis do not readily explain the organisational determinants of change. However, the integration of sociotechnical theory can inform more effective strategies. Our specific aims were to (1) describe a computerised decision support intervention intended to improve adherence with deep venous thrombosis (DVT) prophylaxis recommendations; and (2) show how sociotechnical theory expressed in ‘Fit between Individuals, Task and Technology’ framework (FITT) can identify and clarify the facilitators and barriers to QI work.

Methods A multidisciplinary team developed and implemented electronic menus with DVT prophylaxis recommendations. Stakeholders were interviewed and human factors were analysed to optimise integration. Menu exposure, order placement and clinical performance were measured. Vista tool extraction and chart review were used. Performance compliance pre-implementation was 77%.

Results There were 80–110 eligible cases per month. Initial menu use rate was 20%. After barriers were classified and addressed using the FITT framework, use improved 50% to 90%. Tasks, users and technology issues in the FITT model and their interfaces were identified and addressed. Workflow styles, concerns about validity of guidelines, cycle times and perceived ambiguity of risk were issues identified.

Conclusions DVT prophylaxis in a surgical setting is fraught with socio-political agendas, cognitive dissonance and misaligned expectations. These must be sought and articulated if organisations are to respond to internal resistance to change. This case study demonstrates that QI teams using information technology must understand the clinical context, even in mature electronic health record environments, in order to implement sustainable systems.


  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the A QI/QA expedited review was issued by facility IRB—This was a quality improvement initiative; the intervention was applied uniformly to surgical patients and staff as a QI action—non-standard care was neither extended or withheld from a patient cohort—providers were not enrolled in treatment arms.

  • Provenance and peer review Not commissioned; externally peer reviewed.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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