Integration of Evidence-Based Practice, Quality Improvement, and Research as Part of the Magnet Journey

1. Integration of Evidence-Based Practice, Quality Improvement, and Research as Part of the Magnet Journey Kathleen M Buckley, PhD, RN, IBCLC Associate Professor University of Maryland School of Nursing

2. Objectives • Compare and contrast the major tenets of Evidence-Based Practice (EBP), Quality Improvement (QI), and research • Review examples of EBP, QI and research • Describe a model for the integration of EBP

3. 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.

4. 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

5. What are some of the key strategies that can be used by a hospital to create a high reliability organization?

6. Key Strategies Quality Improvement Evidence-based practice Research EBP can reduce healthcare costs by as much as 30%!

7. Gardening

8. What Are 3 basic elements in creating a garden? Soil Water Sunlight

9. 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.

10. EBP within the Context of Caring Melnyk, B.M., 2012

11. 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.

12. Research • systematic investigation • including research development, testing and evaluation • designed to develop or contribute to generalizable knowledge Dept of HHS, 2005

13. 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

14. Differentiating QI & 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 Quality Improvement Research

15. 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.

16. Risks of QI presented as research • Credibility of findings would be questioned • Patients’ rights are not protected • Sanctions are imposed by IRB for noncompliance

17. Examples of EBP, QI and research in Nursing

18. Evidence-Based Practice

19. 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

20. EBP Process • Defined terms clearly • Developed search algorithms • Reviewed literature with structured templates • Wrote annotated bibliographies • Created a table evaluating the evidence • Identified common themes • Formulated a policy based on synthesis of literature

25. Quality Improvement

26. QI Project: Prevention Retained Surgical Items (RSI)

27. 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

28. QI Project • reviewed reported incorrect counts and count discrepancies • collaborated with the radiology department • reviewed and revised the existing count policy • root cause analysis

29. 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

30. 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

31. Radiology cost associated with count discrepancies

32. Research

33. 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 scale Gavronsky et al., 2012, Pain Management Nursing

36. What is the final Essential element for Gardening?

37. Model: integration of EBP Turkel, M.C. et al, 2005, Nurse Admin Q

38. 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

39. Nursing Staff meetings • Research committee

40. Navigating internal resources • Educational sessions • Journal clubs

41. Critiquing the literature • Validate or change in practice • Scholar or fellowship

42. Review of the literature • Proposal to Nursing Research Committee and IRB • Collecting data • Article publication

43. 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

44. Philosophy of Successful Gardening • Grow something that likes you  • Learn something   • Experiment   • 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

45. 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.

46. Questions or comments?