Integration of Evidence-Based Practice, Quality Improvement, and Research as Part of the...
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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?