Distinguishing Between Quality Improvement, Evidence-Based Practice, and Nursing Research Maria R....
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Distinguishing Between Quality Improvement, Evidence-Based Practice, and Nursing Research Maria R. Shirey, PhD, MBA, RN, NEA-BC, ANEF, FACHE, FAAN Professor, Community Health, Outcomes & Systems Assistant Dean, Clinical Affairs & Partnerships University of Alabama at Birmingham School of Nursing North Dakota Center for Nursing Conference October 23, 2014 • Bismarck, North Dakota
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Distinguishing Between Quality Improvement, Evidence-Based Practice, and Nursing Research
Maria R. Shirey, PhD, MBA, RN, NEA-BC, ANEF, FACHE, FAANProfessor, Community Health, Outcomes & Systems
Assistant Dean, Clinical Affairs & PartnershipsUniversity of Alabama at Birmingham School of Nursing
North Dakota Center for Nursing ConferenceOctober 23, 2014 • Bismarck, North Dakota
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Introduction
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So … How Did You Get Here?
“Showcasing Differences Between Quality Improvement,
Evidence-Based Practice, and Research”
Shirey et al., (2011)
Winner of the inaugural JCEN Innovation Award for 2011
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Impact
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Presentation Objectives
• Differentiate among quality improvement (QI), evidence-based practice (EBP), and nursing research
Realistic Expectation:
Gain general understanding of concepts and their applicationReflect and brainstorm to use information more broadly
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Road Map
• Overview of the Shirey et al., (2011) article
• Application of article by others • Reflective dialogue with next steps
• Key takeaways with Q&A
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Overview of the Article
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Why Is There Need to Know?
• Recent meta-analysis identified all concepts as essential for Magnetic, healthy nursing workplace (Kramer, Schmalenberg & Maguire, 2010)
Quality & Safety of Patient Care
Research
EBPQI
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Important Definitions
Quality Improvement
Data driven systematic approach by which individuals work together to improve specific internal systems, processes, costs, productivity, and quality outcomes with an organization
Note: Terms QI and Performance Improvement (PI) used interchangeably
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Important Definitions
Evidence-Based Practice
Problem-solving approach that integrates a systematic search for and critical appraisal of the best available evidence (may or may not be research based) to answer a burning clinical, education, or administrative question
Clinician expertise and patients’ unique circumstances and preferences
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Important Definitions
Research
Scientific process that generates new knowledge and validates/refines existing knowledge that directly and indirectly influences nursing practice or health systems
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Background and Overview of the Article
• Started as discussion board assignment in DNP course
• Intent of assignment was to compare and contrast all 3 concepts of QI, EBP, Research across multiple dimensions
• No article available with extensive side-by-side comparative data, so … we created one!!!
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Building The Comparative TableSynthesis of the Literature
Main Categories QI EBP Research
Background and descriptors
Uses and Applications
Scholarship Integration
Shirey et al. (2011)
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Highlights of Comparative Table
Main Categories with Dimensions
QI EBP Research
Background and descriptors• Historical
evolution
• Commonalities and distinctions
• Key features
• Rigor
Deming; production quality monitoring
Systematic problem solving approach that is data driven
Incorporatesknowledge
Least rigorous
Cochrane; scientific evidence used to guide practice
Systematic problem solving approach that is evidence driven
Translates knowledge
Somewhat rigorous
Nightingale; scientific method of discovery in nursing
Systematic problem solving approach that is inquiry driven
Generatesknowledge
Most rigorous
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Highlights of Comparative Table
Main Categories with Dimensions
QI EBP Research
Uses and Applications• Purpose
• Use of protocols
• Data collection
• IRB approval
Improve internal processes to enhance outcomes
Yes; changing
Rapid cycle
Not usually; may be needed for pubs
Evaluate evidence and integrate into practice to enhance outcomes
Yes; systematic
Intermediate not rapid cycle
Not usually; may be needed for pubs
Develop new knowledge that is generalizable
Yes; strict
Not rapid cycle
Always; required for publication and to initiate study
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Highlights of Comparative Table
Main Categories with Dimensions
QI EBP Research
Uses and Applications• Funding
• Oversight
• Limitations
• Methodology
Usually internal
Institutional
Weak methodology;no causality
Various QI approachesi.e. PDCA
Usually internal
Institutional
Outcome only as good as “best” evidence
Various EBP modelsi.e. ARCC model (Melnyk & Fineout-Overholt)
May be internal or external
Beyond institution
Depending on analysis can establish causality
Various methodologies i.e. qualitative, quantitative or mixed methods
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Highlights of Comparative Table
Main Categories with Dimensions
QI EBP Research
Uses and Applications• Examples PDCA project to
improve door to balloon times in acute myocardial infarction patients
PDCA project to reduce 30-day hospital readmission rates in heart failure patients
Implementation of protocol for early post operative patient ambulation following release of landmark systematic review
Translation of best evidence into practice to enhance outcomes
Qualitative research to describe nurse manager work complexity
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Highlights of Comparative Table
Main Categories with Dimensions
QI EBP Research
Scholarship Integration• Theoretical
underpinnings
• Generalizability
• Expectations for dissemination
• Potential for dissemination
No
No
Within facility
May be publishable
Varies
Yes, with caveat
Within facility and beyond
May be publishable
Usually yes
Yes, with caveat
Broad dissemination to scientific community
Usually publishable
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Highlights of Comparative Table
Main Categories with Dimensions
QI EBP Research
Scholarship Integration• Examples of
venues for publication
• Examples of venues for presentations
Journal for Healthcare Quality
NAHQ conferences
Worldviews on Evidence-Based Practice
EBP conferences
Nursing Research
Nursing research society conferences
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Understanding Check
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Understanding Check
Question #1If the intent of a project is to establish a cause-and-effect relationship, the best approach to use would be a/an:A. Evidence-Based Practice Project.B. Quality Improvement Project.C. Research Project.D. Institutional Project.
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Understanding Check
Question #2Given the following choices to develop an EBP project, the best methodology to use would be:A. Six Sigma.B. Plan Do Check Act.C. The Academic Model.D. The Iowa Model.
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Understanding Check
Question #3Given the choice between various approaches, a team developing a clinical work flow process using limited resources and time would likely select:A. Nursing Research.B. Evidence-Based Practice.C. Quality Improvement.D. Clinical Inquiry.
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Understanding Check
Question #4The definitive dimension the distinguishes between quality improvement, evidence based practice, and research is:A. Historical Evolution.B. Definition.C. Rigor.D. Purpose.
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Application of the Article
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The ApplicationTool for Academia
• Guide for teaching QI, EBP, Research in academic programs
• Incorporated in teaching QSEN principles (American Association of Colleges of Nursing QSEN Institute Faculty Resources)
• Referenced in numerous professional websites
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The ApplicationTool for Clinical Nursing Excellence
• Support Nursing Standards of Practice (ANA, 2010)
At fundamental level, the registered nurse participates in QI activities and integrates EBP and research into practice
• Accelerate Hospital Magnet Journey → Guide to decipher which approach to use → Identify need for IRB approval → Create Magnet evidence
• Form foundation for additional user-friendly staff development resources for clinical practice (Ryan & Rosario, 2012)
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The ApplicationTool for Clinical Nursing Excellence
Performance Improvement/Research Differentiation Form(Ryan & Rosario , 2012)
• Identify title of project
• Answer series of questions
• Determine pattern of responses
• Identify emerging dominant study category
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Ryan & Rosario (2012)
Performance Improvement
Research Uncertain
Which phrase best describes purpose of the project?
To improve internal organizational processes, practices, costs or productivity
To generate new knowledge that can be generalized
What are you trying to accomplish with this project?
To measure an existing practice that is an approved procedure or that has been shown effective in the literature
*** To test or refine an innovative practice or instrument
Will participants be placed at any risk during project?
The project does not impose risks beyond usual care
*** The project may impose some risk to participants
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Ryan & Rosario (2012)
Performance Improvement
Research Uncertain
What does the intervention in this project involve?
The project involves applying practice standards or evaluating existing practice without group comparisons
The project involves comparisons of one or more interventions that are given to some patients and not others
How are the processes or outcomes measured?
A data collection tool that has not been tested for reliability and validity is used
An instrument that is a valid and reliable measure of the concept to be tested will be used
What do you plan to do with the findings?
Communicate findings within the hospital or department setting. Findings may be published and/or presented.
Publish and/or present findings for others within the discipline
How will your findings change practice?
May change practice in this setting immediately
May change practice slowly, often after multiple studies validate the results
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The ApplicationTool for Dissemination
Different Formats for Publication of QI, EBP, ResearchOermann, Turner & Carman (2014)
Guidelines for
Reporting
ResearchIMRAD
QISQUIRE
EBPPRISMA
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The ApplicationTool for Dissemination
Guideline Definition and Website Resource Categories
QI SQUIRE Standards for Quality Improvement ReportingExcellencehttp://squire-statement.org/
Title, Abstract, Introduction, Methods, Results, Discussion, Other Information
EBP PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyseshttp://www.prisma-statement.org/
Title, Abstract, Introduction, Methods, Results, Discussion, Funding
Research IMRAD Introduction, Methods, Results, and Discussionhttp://writingwisc.edu/Handbook/ScienceReport.html
Title, Abstract, Introduction, Methods, Results, Discussion, Limitations, Conclusions, Implications, Funding
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Application Check
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Application Check
Scenario #1: QI• The hospital examines its monthly run charts on key
quality indicators
• In reviewing these data, the hospital determines the incidence of falls in hospitalized elderly patients is trending upward
• To act on this information, what should happen next?
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Application Check
Scenario #1: QI• Formulate QI question: Why is the unit level fall rate so high?
• Apply QI methodology P Identify and analyze problem D Develop and test solutions C Check effect of pilot solution A Implement solution fully
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Application Check
Scenario # 2: EBP• There is a desire to initiate a practice change that
would prevent falls in hospitalized elders
• To initiate a practice change, what should happen first?
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Application Check
Scenario # 2: EBP• Formulate clinical question using PICOT format: P Population I Intervention C Comparison O Outcome T Timeframe
In hospitalized elders (P), how does a bed alarm (I) compared to use of sitters (C) affect fall rates (O) during a 3 month time period (T)? 38
Application Check
Scenario # 2: EBP• Specify key search terms to retrieve evidence that best
answers PICOT question and meets inclusion criteria
• Generate evidence table and determine level of evidence
• Critically appraise the evidence (look at flaws and worth)
• Make practice recommendations based on best evidence
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Application Check
Level 1- Systematic review & meta-analysis of RCT
Level 2- One or more randomized controlled trials
Level 3- Controlled trial (no randomization)
Level 4- Case control or cohort study
Level 5- Systematic review of descriptive & qualitative studies
Level 6- Single descriptive or qualitative study
Level 7- Expert opinion
Melnyk & Fineout-Overholt (2011)40
Application Check
Scenario # 3: Research• You have searched the literature to obtain information about
the incidence of falls in hospitalized elders
• You find the literature is not current and it does not incorporate cultural aspects pertinent to your unique elderly patient population
• How do you go about developing a permanent solution for elderly patient falls in your patient population?
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Application Check
Scenario # 3: Research• Identify problem statement
• Formulate research question: What factors contribute to falls in non-English speaking hospitalized elderly patients?
• Use research question to guide methodology (design, sampling, data collection, data analysis methods)
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Reflection with Next Steps
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Stretch and Energize to Focus
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Reflective Question
Now that you have heard this presentation, what ideas do you have for HOW you would
immediately begin using the information in your practice and work setting?
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Think, Pair & Share
• Turn to person next to you
• Discuss the following for 5-minutes: How would you begin to immediately use the information from this presentation in your practice and/or work setting?
What partnerships or networks might you leverage? Why?
• Take 5-minutes to share your ideas with the broader audience
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Synthesis Check
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Key Takeaway Points
• Correctly differentiating among QI, EBP, and research = → Essential for patient care quality/safety
→ Needed to advance nursing practice and science
• Understanding concept differences enhances applicability, integration, collaboration opportunities, and ultimately our IMPACT
• Proficiency comes from learning and doing
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Closing
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Questions & Answers
Maria R. Shirey, PhD, MBA, RN, NEA-BC, ANEF, FACHE, FAANProfessor, Community Health, Outcomes & Systems
Assistant Dean, Clinical Affairs & PartnershipsUniversity of Alabama at Birmingham School of Nursing
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References
American Nurses Association. (2010). Nursing scope and standards of practice. Washington, DC: ANA.
Kramer, M., Schmalenberg, C.& & Maguire, P. (2010). Nine structures and leadership practices essential for a magnetic (healthy) work environment. Nursing Administration Quarterly, 34(1), 4-17.
Melnyk, B. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.
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References
Oermann, M.H., Turner, K. & Carman, M. (2014). Preparing quality improvement, research, and evidence-based practice manuscripts. Nursing Economic$, 32(2), 57-69.
Ryan, M. & Rosario, R. (2012). Creating staff confidence in distinguishing between performance improvement and research studies: A user-friendly worksheet. Journal of Nursing Administration, 42 (7/8), 369-374.
Shirey, M. R., Hauck, S. L., Embree, J. L., Kinner, T. J., Schaar, G. L., Phillips, L. A., Ashby, S. R., Swenty, C. F., & McCool, I. A. (2011). Showcasing differences between quality improvement, evidence-based practice, and research. The Journal of Continuing Education in Nursing, 42(2), 57-70.
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