INTEGRATION OF EVIDENCE-BASED PRACTICE, QUALITY IMPROVEMENT, AND RESEARCH AS PART OF THE MAGNET JOURNEY

Kathleen M Buckley, PhD, RN, IBCLCAssociate ProfessorUniversity of Maryland School of Nursing

OBJECTIVES1. Compare and contrast the major

tenets of Evidence-Based Practice (EBP), Quality Improvement (QI), and research

2. Review examples of EBP, QI and research

3. Describe a model for the integration of EBP

COST OF LOW QUALITY HEALTHCARE Low quality healthcare cost the United

States about $720 billion Wasteful healthcare spending costs the

healthcare system $1.2 trillion annually

Midwest Business Group on Health, Juran Institute & The Severyn Group, 2003.

HIGH RELIABILITY HEALTHCARE ORGANIZATION A high reliability healthcare organization

provides care that is safe and one that minimizes errors while achieving exceptional performance in quality and safety.

Pronovost, P.J., 2006, HSR: Health Services Research

What are some of the key strategies that can be used

by a hospital to create a high reliability organization?

KEY STRATEGIES

Quality Improvement

Evidence-based practiceResearch

EBP can reduce healthcare costs by as much as 30%!

GARDENING

WHAT ARE 3 BASIC ELEMENTS IN CREATING A GARDEN?

Soil

Sunlight

Water

EVIDENCE-BASED PRACTICE (EBP) problem solving systematic approach to

clinical decision making integrates

best available scientific research experiential evidence, and patient’s preferences and values

contributes to improved outcomes

Newhouse et al, 2005.

EBP WITHIN THE CONTEXT OF CARING

Melnyk, B.M., 2012

QUALITY IMPROVEMENT (QI) systematic activity guided by data to study clinical processes and outcomes designed to bring about immediate

improvement in care in local setting

Baily et al, 2006.

RESEARCH systematic investigation including research development, testing

and evaluation designed to develop or contribute to

generalizable knowledge

Dept of HHS, 2005

SIMILARITIES BETWEEN QI AND RESEARCH intent of both – to improve process of

care or practice outcomes or health & well-being of populations

both have a clear responsibility to act in an ethical and moral manner

both must protect patient rights at all times & act in a professionally accountable manner

DIFFERENTIATING QI & RESEARCH

Quality Improvement Research

purpose: to improve current practice in a particular setting

data is confidential action is within

existing standards of care

IRB approval is not usually necessary

purpose: create generalized knowledge

desire to publish/present

action involves testing new methods

needs IRB approval

QI OR RESEARCH?IRB OR NOT? Testing use of a well-known IV catheter

to see if it decreases the risk of infiltration.

Testing use of innovative double-lumen catheter to see it decreases the risk of infiltration.

Presenting at an academic meeting about the impact of QI efforts on average Hemoglobin A1c levels.

Tracking average Hemoglobin A1c levels to assess a hospital's performance on diabetes care.

RISKS OF QI PRESENTED AS RESEARCH Credibility of findings would be

questioned Patients’ rights are not protected Sanctions are imposed by IRB for

noncompliance

EXAMPLES OF EBP, QI AND RESEARCH IN NURSING

EVIDENCE-BASED PRACTICE

USING EBP TO EVALUATEINFECTION CONTROL POLICIESIN THE PERIOPERATIVE ENVIRONMENT

Nurses working in Army Military medical centers

Problem: lack of clear policy for decontamination of noncritical equipment

Freeman et al., 2009, AORN Journal

EBP PROCESSDefined terms clearlyDeveloped search algorithmsReviewed literature with structured

templatesWrote annotated bibliographiesCreated a table evaluating the evidence Identified common themesFormulated a policy based on synthesis of

literature

QUALITY IMPROVEMENT

QI PROJECT: PREVENTION RETAINED SURGICAL ITEMS (RSI)

QI PROJECT: PREVENTION RETAINED SURGICAL ITEMS Purpose: to reduce incorrect counts and

prevent retained surgical items

E.K. NORTON, BSN, RN, CNOR; C. MARTIN, RN, CNOR; A.J. MICHELI, MS, RN, NEA-BC;2012, AORN Journal

QI PROJECT reviewed reported incorrect counts and

count discrepancies collaborated with the radiology

department reviewed and revised the existing count

policy root cause analysis

ROOT CAUSE ANALYSIS OF CONTRIBUTING FACTORS surgical procedures that lasted longer

than 8 hours multiple staff turnovers during a

procedure documentation discrepancies or

omissions of items added to the surgical field

communication breakdown a lack of standardized practice due to

variability interpretation of count policy

QUALITY IMPROVEMENT PROJECT (CONT) used a team approach

Invested in radio frequency technology for sponge count

Revised requisition form for radiology to clarify item deemed missing

Revised the count policy to standardize practice

Embedded the wound closure time out in the Pediatric Surgical Safety checklist

conducted observational audits

RADIOLOGY COST ASSOCIATED WITH COUNT DISCREPANCIES

RESEARCH

STUDY OF POST-OP PAIN:ACUPUNCTURE VS. ACUPUNCTURE WITH PENS Purpose: Improve management of post-

op gynecological surgical pain Sample/Setting: 20 patients from 30-82

years in a New England medical center Design: experimental comparison group Method:

Randomly assigned subjects to 2 groups: Acupuncture with or without PENS

Measured pain within 24-48 hours after surgery

Used Visual Analogue Pain scaleGavronsky et al., 2012, Pain Management Nursing

WHAT IS THE FINAL ESSENTIAL ELEMENT FOR GARDENING?

Step 4Implementin

g EBP

Step 5 Contributing

to a Research

Study

Step 1Establishing

a Foundation

for EBP

Step 2Identifying Areas of Concern

Step 3Creating Internal

Expertise

Turkel, M.C. et al, 2005, Nurse Admin Q

MODEL: INTEGRATION OF EBP

Leadership commitment

Involvement of APNs EBP as part of Annual

Performance Review EBP as part of Clinical

Ladder Placement Securing resources Forming a Nursing

Research committee

Nursing Staff meetings

Research committee

Navigating internal resources

Educational sessions

Journal clubs

Critiquing the literature

Validate or change in practice

Scholar or fellowship

Review of the literature

Proposal to Nursing Research Committee and IRB

Collecting data Article publication

WHY ENGAGE IN EBP? Nurses support that engaging in EBP

renews the professional spirit of the nurse, a key variable in professional satisfaction.”

Maljanian, R. et al, 2002, JONA

Nurses comment that ‘‘EBP gives us a voice and allows us to reclaim our authentic self as a ‘real nurse’ as well as supports us to become strong patient advocates, focused on improving the quality of the care given to patients.” Strout, T.D., 2005, Sigma Theta Tau

PHILOSOPHY OF SUCCESSFUL GARDENING1. Grow something that likes you 2. Learn something  3. Experiment  4. Make a long-range plan  

Think about how the landscape you govern represents the footprint that you leave behind you on this earth.

Tom Clothier

REFERENCES Baily, M.A., Bottrell, M., Lynn, J. & Jennings, B. (2006). The ethics of using QI methods to improve

health care quality and safety. Hastings, 36(4). S1-S40. Department of Health and Human Services. (2005). Code of federal regulations. Freeman, S.S., Lara, G.L., Courts, M.R., Wanzer, L.J., & Garmon, S.C. (2009). An evidence-based

process for evaluating infection control policies. AORN Journal, 89(3), 489- 507. Gavronsky, S., Koeniger-Donohue, R., & Hawkins, J.W. (2012). Postoperative pain: Acupuncture

versus percutaneous electrical nerve stimulation. Pain Management Nursing, 13(3), 150-156. Maljanian, R. et al. (2002).Evidence-based nursing practice, Part 2: building skills through research

roundtables. Journal of Nursing Administration 32(2), 85-90 Melnyk, B.M & Fineout-Overholt. (2012). The State of Evidence-Based Practice in US Nurses. JONA,

42(9), 410-417. Midwest Business Group on Health in collaboration with Juran Institute & The Severyn Group.

(2003). Reducing the Costs of Poor-Quality Health Care through Responsible Purchasing Leadership.

Newhouse, R.P., Dearholt, S. Pugh, L.C., & White, K. (2005) Evidence-based practice: A practical approach to implementation. Journal of Nursing Administration, 35(1), 35-40.

Norton, E.K., Martin, C., Micheli, A.J. (2012). Patients count on it: An initiative to reduce incorrect counts and prevent retained surgical items, AORN Journal, 95 (1), 109-121.

Provonost, P.J. (2006). Creating High Reliability in Health Care Organizations HSR: Health Services Research, 41(4), 1599-1617.

Strout ,T.D. C(2005). Curiosity and Reflective Thinking: Renewal of the Spirit. Indianapolis, IN: Sigma Theta Tau International.

Turkel , M.C., Reidinger, G., Ferket, K., & Reno, K. (2005). An essential component of the magnet journey: fostering an environment for evidence-based practice and nursing research Nurse Administration Quarterly, 29(3), 254-262.

QUESTIONS OR COMMENTS?