Implementing evidence-based practice at the microsystem level

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Implementing evidence-based practice at the
microsystem level

• Susan W. Salmond, RN, EdD
• Professor, Interim Dean
• UMDNJ School of Nursing
• Co-Director, NJ Center for EBP
• salmonsu_at_umdnj.edu

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The Institute of Medicine Committee on Quality of
Health Care in America
Has Issued a Call to Arms..
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In its current form, habits, and environment,
American health care is incapable of providing
the public with the quality health care it
expects and deserves.
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6 Target Areas for Improvement
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1. Safety
Patients ought to be as safe in health care
facilities as they are in their own homes
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2. Effectiveness
The health care system should match care to
science, avoiding both overuse of ineffective
care and underuse of effective care
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3. Patient Centeredness
Health care should honor the individual patient,
respecting the patients choices, culture, social
context, and specific needs
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Care should continually reduce waiting times and
delays for both patients and those who give care
4. Timeliness
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5. Efficiency

• The reduction of waste and, thereby, the
  reduction of the total cost of care should be
  never ending, including, for example, waste of
  supplies, equipment, space and human spirit

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6. Equity
The system should seek to close racial and ethnic
gaps in health status
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How to Get These Improvements?

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Focus on the Microsystem

• The small units of work that actually give the
  care that the patient experiences
• Consists of a small team of people, combined with
  their local information system, a client
  population and a defined set of work processes

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3 Design Principles for Microsystem Redesign

• Knowledge-Based Care
• Use of best scientific and clinical information
• Patient-Centered Care
• Patients put in control of their own care-
  customization according to individual needs,
  desires and circumstances
• Systems-Minded Care
• Assumes responsibility for coordination,
  integration, and efficiency across traditional
  boundaries of organization, discipline and role

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No Clear Cut Path to Achieving Best Practices at
the Microsystem Level
CNL Plays a Leadership Role in the Microsystem
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EBP and Quality go hand-in-hand

• IOM
• NQF
• ANA
• JCAHO
• IHI
• CMS

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Who is paying attention to EBP?
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Healthcare s New Mantra

• Show Me the Evidence!!

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Evidence Based Practice
Practice Based Evidence
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ASSURE BALANCE
Practice Tyrannized By External Evidence
Out of Date Practice Obsolete
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Balance Between Evidence and Expertise

• Without clinical expertise, practice risks
  becoming tyrannized by external evidence, for
  even excellent external evidence may be
  inapplicable to or inappropriate for an
  individual patient. 
• Without current best external evidence, practice
  risks becoming rapidly out of date, to the
  detriment of patients.
• 
  (Sacket, 1997)

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Evidence is not Black and White

• Use it to inform Clinical Practice

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Evidence is Multifaceted
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Multiple Ways of KnowingEvidence includes.

• Scientific findings
• Different questions answered best by different
  methods
• NOT just a focus on the RCT
• Practice-based evidence
• Consensus recommendations
• Affirmed experiences in clinical practice
• Ethical, aesthetic, sociopolitical ways of knowing

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Patient Issue/Question Practice Based Evidence
Process of EBP
Assess
Ask
Acquire
Improved Outcomes Improved Patient Experience
Having the Best Evidence Does Not Guarantee Its
Use in PracticeKnowledge Translation Science
Appraise
Act
Evidence to Match Question
Apply?
Evidence alone does not decide combine with
other knowledge , clinical context and patient
values
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Our Path Today

• Examine CNL Role in Overcoming Barriers to EBP-as
  the EBP Champion
• Identify approaches to advance the knowledge and
  Skill Set for 4 EBP Levels
• Identify S/W in own EBP skill set
• Describe strategies for translating evidence into
  practice

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CNLOvercoming Barriers to EBP
Barrier CNL Action
Lack of Time CNL role structured in the microsystem without direct care responsibility facilitates prioritization of obtaining and evaluating datathe evidence
Most nurses practice nursing according to what they learned in nursing school. CNL has current knowledge base and seeks information as needed. Commitment to Self-Inquiry Readiness to change practice
Interventions based on experience and advice of other colleagues CNL also turns to the evidence. Is skilled in accessing information at the point of care to answer questions.
Consistent finding across the international
literature (Olade, 2004).
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CNLOvercoming Barriers to EBP
Barrier CNL Action
Unfamiliarity with how to search data bases, i.e., CINAHL, MEDLINE CNL develops skill in accessing data bases and point of care information sources. Works with Clinical Librarian
Inability to read and critique research literature Critically appraises and mentors others to C.A. research . Draws on internal and external experts to assist. Coordinates with administration educational programs and skill development plans
Lack of access to sources of evidence Advocates for nursing access to electronic evidence resources. Facilitates distribution or awareness of relevant information /resources
Lack of authority/autonomy to implement best practice findings Skilled in lateral integration. Builds working relationships with common goal of improved patient outcomes.
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CNLOvercoming Barriers to EBP
Barrier CNL Action
Lack of Organizational Support Keep EBP in the forefrontin rounds, in meetings, use of research consultants
60 had not identified a researchable problem in past year (Pravikoff, 2005) CNL is a reflective practitioner. Identify trends and areas where data is needed. Through patient interaction and clinical data analysis asks about timeliness, effectiveness, efficiency, safety
Research studies show that only small number know what evidence-based practice is (Pierce, 2000 Tanner, 2000 Pravikoff, 2005) CNL understands EBP and is the microsystem leader in bringing it about.model it, teach others about it, act on it
Used to traditional methods of learning- receiving journals, reading articles Develop skills in real time learning
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Just in Time LearningThe EBM Approach to
Education

• Shift focus from reading what comes to you, to
  finding information about current patient
  problems(just in time education)
• Relevant to YOUR practice
• Memorable and behaviour changed!
• Up to date
• Skills and resources for best current answers

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Growing Needed Expertise

• Making Evidence Based Practice come alive at the
  microsystem level
• Tracking results of Evidence Based Practice
  creates data on CNL effectiveness

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Action Planning Implementation
Determine Applicability
Critically Appraise Search Data Bases Search
Pre-Appraised Lit Ask Searchable Questions
Develop a Climate of Clinical Inquiry
Analyze Practice Based Data
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Clinical Inquiry

• The New ParadigmAcross the Microsystem Team
• Why am I doing what I am doing?
• Do I have evidence to support what I am doing?
• Is my current practice the best for my
  patients?
• Are there better ways of providing care?
• What have I learned?
• What information do I need?
• Sharing questions, need for information/evidence
• What areas can we build on?

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Cultures of Clinical Inquiry
The Picture

• Across the interdisciplinary team, there is
  comfort in Questioning Why?
• Members adopt reflective practices individually
  and in groups to think about what is and what
  should be
• There are means to participate in formalized
  reflection and learning activities to advance
  best practices.

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Cultures of EBP..Build on Clinical Inquiry
The Picture

• Nursing practice is based on best available
  evidence and evidence is continually reviewed
  towards continual improvement
• Sense of inquiry which is transformed into
  questionsthis starts the EBP process of
  searching for evidence
• Caregivers are empowered to answer questions and
  make practice recommendations
• Practice change is built into protocols,
  structures and monitoring mechanisms

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Creating Cultures of Clinical Inquiry

• Becoming Reflective
• Dialog with Peers, Mentors (Errington and
  Robertson, 1998)
• Need to share observation and thoughts with
  someone who will provide a sounding board, open
  up different perspectives, and provide support
  and guidance
• What supports are needed to strengthen nursing
  care to reach desired patient outcomes?
• What are recurring issues? Why do they
  occur/recur? Are there new solutions to moving
  beyond these issues?
• What is EBP? Why is it needed? How can it improve
  nurse and patient outcomes?

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Creating Cultures of Clinical Inquiry

• Becoming Reflective
• Clinical Rounds
• What questions emerge? What variation for
  different backgrounds? Invite patient in question
  building. Invite librarians
• Clinical Coaching
• A relationship for the purpose of building skills
  (not just providing information)
• Promotion of skills using processes of critical
  thinking and problem solving
• Case analyses, audit data

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Creating Cultures of Clinical Inquiry

• Becoming Reflective
• Recording Questions, Experiences, Reflections
• Logs to Capture Questions, Write Down Patient
  Problems
• Journaling (Zubbrizarreta 1999 and Tryssenaar
  1995 )
• Professional Development Diaries (Clouder 2000)
• Analysis and Discussion of Practice Based Data
• Patient Call Backs, Focus Groups
• QI Data Review
• Nursing MM

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Creating Cultures of Clinical Inquiry

• Becoming Reflective
• Recording Experiences, Questions, Reflections
• Logs to Capture Questions, Write Down Patient
  Problems
• Journaling (Zubbrizarreta 1999 and Tryssenaar
  1995)
• Professional Development Diaries (Clouder 2000)
• As the thoughts, observations or questions occur
• As more formal reflections
• Writing adds a different perspective or clarity

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Creating Cultures of Clinical Inquiry

• Role Modeling

• If you do it, and are seen by others to do it,
  gives you legitimacy when you ask them to do it
• Reflection leads to questions and a willingness
  to look at new approaches

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Action Planning Implementation
Determine Applicability
Critically Appraise Search Data Bases Search
Pre-Appraised Lit Ask Searchable Questions
Develop a Climate of Clinical Inquiry
Analyze Practice Based Data
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Analysis of Practice Based DataMay feed into or
out of clinical inquiry

• Varied types of Practice Based Data
• Individual or group retrieval
• Trend data
• Visual presentations of data

• Patient Call Backs
• Focus Groups
• QI Data, Outcome Data
• Retrospective Chart Review
• Nursing MM
• Satisfaction Surveys
• Communications

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Action Planning Implementation
Determine Applicability
Critically Appraise Search Data Bases Search
Pre-Appraised Lit Ask Searchable Questions
Develop a Climate of Clinical Inquiry
Analyze Practice Based Data
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Level 2

• EBP process begins and ends with a well-designed
  question
• Focused Questions that yield retrievable,
  manageable information -PICO(T)
• To Move to this level will need Education on What
  is EBP and How to Ask Clinical Questions

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Transforming Clinical Question into Searchable
Question

• PICO(T) Question

P Population Population
I Intervention or Issue of Interest Phenomenon of Interest
C Comparison Context
O Outcome of Interest
T Time
Question
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Transforming Clinical Question into Searchable
Question

• PICO(T) Question

P Patient In adult patients following spinal tap procedures
I Intervention or Issue of Interest Does Bedrest
C Comparison Compared to No Bedrest
O Outcome of Interest Result in Decreased Incidence and Severity of Headaches
T Time In first 4-8 hours post procedure
Question
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Transforming Clinical Question into Searchable
Question

• PICO(T) Question

P Patient In older adults with a risk for falls
I Intervention or Issue of Interest Does the use of hip protectors
C Comparison Compared to No hip protectors
O Outcome of Interest Result in Decreased Incidence of Hip Fractures
T Time Occurring with Accidental Falls
Question
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Transforming Clinical Question into Searchable
Question

• PICO(T) Question

P Population For Adult Children
I Intervention or Issue of Interest Stressors Associated with Decision Making
C Comparison In Placing a Parent in a Nursing Home
O Outcome of Interest
T Time
Question
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Hoot Groups for Learning to Ask Retrievable
Questions

• Groups of 2 3
• Discuss gt1 question from recent work
• Write it down using the PICOT framework
• Be ready to report to group
• Return in 2 minutes

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Level 2

• Retrieving Point-of-Care Evidence
• Searching synthesized or pre-appraised literature
  at point of care to acquire evidence about PICOT
• Use limited time for selective, efficient,
  patient-driven searching
• Expectation Ease, Quickness, Relevance
• Push diffusion (read it for them, critically
  review it for them, and send it to them)

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Retrieving Point-of-Care Evidence

• Summaries Dynamed, Clinical Evidence, PIER,
  UpToDate, Pepid
• Synopses ACP Journal Club, EBM
• Syntheses/GuidelinesCochrane, JBI, Guideline
  Clearinghouse

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Synopses

• ACP Journal Club
• Evidence Based Medicine
• Evidence Based Nursing

Quality-assessed, clinically rated original
studies and reviews from multiple clinical
journals. With email alerts for own clinical
interests.
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Synopses Evidence-Based Journals
Critical Appraisal Filters
3,500 articles/yr meet critical appraisal and
content criteria (95 noise reduction)
60,000 articles/yr from 120 journals
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Medscape Best Evidence Alerts
Free at https//profreg.medscape.com/px/newsletter
.do
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Syntheses

• Comprehensive Systematic Reviews
• Based on a clearly formulated question
• Identifies relevant studies
• Appraises quality of studies
• Summarizes evidence by use of explicit
  methodology
• Comments based on evidence gathered
• Evidence Based Clinical Guidelines
• Sources
• Cochrane Collaboration
• Joanna Briggs Institute
• AHRQ Evidence Reports and Technology Assessments
• National Guideline Clearinghouse

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Synthesized and Pre-appraised Sources are Key to
Getting Evidence Into Practice
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Clinical Decision Making Based on Evidence

• By the year 2020, 90 of clinical decisions will
  be supported by accurate, timely, and up-to-date
  clinical information and will reflect the best
  available evidence.
• 
  IOM Rountable on EBM

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Facilitating Use of Point of Care Information

• Electronic Medical Record and Clinical Decision
  Supports
• Informatics support
• Clinical Librarian
• Invest in Technology
• Set Expectations for Use
• Work Together Assist Others in Learning Curve
• Determine whether evidence is transferable to
  your patient population

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Learning through play

• Try all buttons
• Make lots of mistakes
• Have fun
• Survey your information environment try to
  influence choices of new resources

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The Evidence
P Patient In adult patients following spinal tap procedures
I Intervention or Issue of Interest Does Bedrest
C Comparison Compared to No Bedrest
O Outcome of Interest Result in Decreased Incidence and Severity of Headaches
T Time In first 4-8 hours post procedure
Question

• Dynamed bed rest for 4 hours following LP does
  not reduce risk for post-LP headache (level 1
  likely reliable evidence)

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The Evidence
P Patient In older adults with a risk for falls
I Intervention or Issue of Interest Does the use of hip protectors
C Comparison Compared to No hip protectors
O Outcome of Interest Result in Decreased Incidence of Hip Fractures
T Time Occurring with Accidental Falls
Question

• Dynamed external hip protectors may reduce risk
  of hip fracture within selected high-risk
  populations, but acceptability problematic due to
  discomfort and practicality (level 2 mid-level
  evidence)

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Transforming Clinical Question into Searchable
Question

• PICO(T) Question

P Population For Adult Children
I Intervention or Issue of Interest Stressors Associated with Transition
C Comparison In Placing a Parent in a Nursing Home

Question
Medline Search 'Making it better'
self-perceived roles of family caregivers of
older people living in care homes a qualitative
study. Found that families and clients were not
adequately prepared for the transition nor was
the facility prepared for the client. Proposes
specific strategies to decrease the transition
stress and facilitate adjustment to the nursing
home environment
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Appraising the Evidence

• Is it valid?
• What are the results?
• Will they help locally?

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Access and Appraisal Skill Sets

• Retrieving evidence from data bases (CINAHL,
  MEDLINE)
• Understanding that best evidence depends on the
  question, not on an inflexible hierarchy
• Critical appraisal of individual studies using
  standardized approaches such as CASP
  http//www.phru.nhs.uk/Pages/PHD/resources.htm
• Understanding of research process
• Statistical Understanding

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Retrieving Evidence
Informatics or Library Mentors for Evidence Mining
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Best Evidence is Question Dependent

• What are the phenomena/ problems?
• What is the experience of.
• What is the frequency of the problem (Frequency)
• Does this person have the problem? (Diagnosis)
• Who will get the problem (Prognosis)
• How can we alleviate the problem (Intervention)

1. Observational Descriptive Studies
2. Observational Descriptive- qualitative
3. Random or Consecutive Sample, Case Controlled
4. Random or consecutive sample compared to a Gold
   Standard
5. Cohort follow up study
6. Randomized Controlled Trial

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Critical Appraisal of Evidence

• Have accessed the evidence, now must determine
  the validity of the evidence
• Do not want to change practice based on poor
  research
• Requires research critique skills..Pull
  Diffusion..teach them to read it so it will be
  used
• Need mentors to assist in skill acquisition

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Promoting Critical Appraisal

• Establish rituals at the microsystem Level that
  promote development of critical appraisal skills
• Interdisciplinary Evidence Based Round Tables
• Journal Clubs
• Grand Rounds Reporting on Educational
  Prescriptions
• Educational Prescriptions
• Contributing to PreAppraised Literature
• CATs, Best BETs, Rapid

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Patient Issue/Question Practice Based Evidence
Process of EBP
Assess
Ask
Acquire
Improved Outcomes Improved Patient Experience
Having the Best Evidence Does Not Guarantee Its
Use in PracticeKnowledge Translation Science
Appraise
Act/Alter
Evidence to Match Question
Apply?
Evidence alone does not decide combine with
other knowledge , clinical context and patient
values
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Clinical Decision Making Based on Evidence

• By the year 2020, 90 of clinical decisions will
  be supported by accurate, timely, and up-to-date
  clinical information and will reflect the best
  available evidence.
• 
  IOM Rountable on EBM
• This cant happen without a better understanding
  of the barriers to translating knowledge into
  practice and strategies to overcome them.

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Knowledge into Practice

• Pulmonary embolism is the commonest preventable
  cause of death in hospitalized medical patients
  (and IOM enemy 1, for patient safety)
• the proportion of medical inpatients receiving
  clot prevention according to guidelines is 33-50
• 
  (Bradley, 2000)
• 84 of Medicare patients with diabetes were not
  tested with the A1c blood test
• National surveys show continued use of sterile
  normal saline instillation before suctioning
• (Schwenker, Ferrin, Gift, 2007)

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Moving Best Practices into Practice
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Knowledge Translation Research

• study of the organization, retrieval, appraisal,
  refinement, dissemination, and uptake of
  knowledge (eg, important new knowledge from
  health research)
• The purpose of using evidence is to have an
  effect on health practice and patient
  outcomes.must get it into practice and
  monitor/evaluate outcomes

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Evidence Into Practice

• Dissemination Communications to
• Raise awareness of research findings
• Facilitate readiness for change
• Encourage consideration of practice alternatives

• Implementation Activities to
• Increase adoption of research findings
• Facilitate changes in practice
• Reinforce and support changes in practice

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Getting Evidence Into Practice

• Greenhalgh T, et al. A systematic review of the
  literature on diffusion, dissemination and
  sustainability of innovations in health service
  delivery and organisation. London, NHSSDO
  Programme, 2004

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The Evidence Action Planning

• Any attempt to bring about change should first
  involve a diagnostic analysis to identify
  factors likely to influence the proposed change.
• Interventions based on assessment of potential
  barriers are more likely to be effective
• Multi-faceted interventions targeting different
  barriers to change are more likely to be
  effective than single interventions.

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Diagnostic Analysis

• Identification of all groups involved in,
  affected by or influencing the proposed change(s)
  in practice
• Assessment of the characteristics of the proposed
  change that might influence its adoption
• Assessment of the preparedness of the health
  professionals to change and other potentially
  relevant internal factors within the target group
• Identification of potential external barriers to
  change
• Identification of enabling factors, including
  resources and skills

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The Evidence Action Planning

• Dissemination activities raise awareness of the
  messages underpinning proposed changes, but by
  themselves they are unlikely to lead to changes
  in practice.
• Passive dissemination is ineffective

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The Evidence Action Planning

• Successful strategies to change practice need to
  be adequately resourced and require people with
  appropriate knowledge and skills (It takes a
  village!)
• Any systematic approach to changing professional
  practice should include plans to monitor and
  evaluate, and to maintain and reinforce any
  change
• Reminder systems are generally effective for a
  range of behaviors

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The Evidence Action Planning

• Know where you are and where you are going-
  Benchmarking
• Appreciative Inquiry Approach with Looking for
  Solutions, Strategies versus deficit planning

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Moving Best Practices into Practice

• Embed evidence-based guidelines into daily
  clinical practice, protocols , clinical pathways
• Observation to monitor compliance
• Tools to monitor
• Audit and Feedback
• Integrate into interdisciplinary rounds
• Use proven provider education modalities to
  support behavior change
• Use standing orders
• Champions

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Knowledge Sharing Networks

• Canada Best Practice Champions Network
• National Nursing Practice Network

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Just In Time Learning.A Lifelong Learning Skill
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Believe You Can Do It Start to Develop the New
Skills
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• The bridge to address all of these improvement
  mandates and to cross the quality chasm is
  evidence-based practice brought alive at the
  microsystem level