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Western Journal of Nursing Research 2014, Vol. 36(7) 929 –946

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Article

The Quality, Implementation, and Evaluation Model: A Clinical Practice Model for Sustainable Interventions

AkkeNeel Talsma1, Margaret McLaughlin1, Melissa Bathish1, Rattima Sirihorachai1, and Rafael Kuttner1

Abstract Major efforts have been directed toward the implementation of sustainable quality improvement. To date, progress has been noted using various metrics and performance measures; however, successful implementation has proven challenging. The Quality, Implementation, and Evaluation (QIE) model, derived from Donabedian’s structure component, presents a framework for implementation of specific activities. The QIE model consists of Policy, Patient Preparedness, Provider Competency, and Performance and Accountability, to guide specific practice initiatives. The implementation of alcohol-based pre-operative skin prep was evaluated in a sample of 17 hospitals and demonstrated that hospitals actively engaged in the components of the model demonstrated a significantly higher use of alcohol-based skin preparation agent than hospitals that did not engage in QIE model activities. The QIE model presents a powerful and actionable implementation model

1University of Michigan, Ann Arbor, USA

Corresponding Author: AkkeNeel Talsma, University of Michigan School of Medicine, 2800 Plymouth Road, NCRC Building 14, D035 Ann Arbor, MI 48109-2800. Email: [email protected]

537121WJNXXX10.1177/0193945914537121Western Journal of Nursing ResearchTalsma et al. research-article2014

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for mid-level management and clinical leadership. Future studies will further evaluate the impact of the specific components of the QIE model.

Keywords implementation model, evidence-based practice, practice evaluation, Donabedian’s model, alcohol-based skin preparation agent

Sustained improvement in quality of care is challenging both the clinical and academic communities despite extensive efforts to improve clinical care and patient outcomes; sustained improvements have been slow, variable, and dif- ficult to attain (Nicholas, Osborne, Birkmeyer, & Dimick, 2010; Pastor et al., 2010; Stulberg et al., 2010). Many interventions cannot be replicated across settings or contexts, and more than half of the implemented interventions may fail (Burnes, 2004). The comprehensive overviews by Damschroder and colleagues (2009) and Greenhalgh, Robert, Macfarlane, Bate, and Kyriakidou (2004) provide important summaries about implementation theories and associated constructs. As knowledge about successful implementation strate- gies emerges and formalizes, one particular area lacks conceptual guidance; for example, the activities clinical leadership needs to implement that con- tribute to a clinician’s adherence to specific evidence-based practices. We aim to address this particular gap in knowledge as it pertains to the imple- mentation of structure related activities that support evidence-based prac- tices. The purpose of this article is to present the Quality, Implementation, and Evaluation (QIE) model, derived from Donabedian’s “Structure” compo- nent, and to review the implementation of the QIE model associated with a sample of evidence-based practice. The QIE model provides an implementa- tion approach for clinical leadership and researchers to modify health system factors and contribute to sustainable health care delivery improvements and to patient outcomes.

Development of a Practice-Oriented Implementation Model

Quality of care has been the focus of many dedicated efforts. Although prog- ress is often noted, sustainable clinical practice improvements have been harder to achieve. Methodologies proven successful in other industries, such as Lean, Six Sigma, and Plan-Do-Check-Act (PDCA) cycles (Six Sigma, 2000) have been adopted into health care with often notable improvements

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(Hughes, 2008). However, research has borne out that successful implemen- tation approaches in a particular setting may not yield the same results when transferred to another setting. Saul, Willis, Bitz, and Best (2013) confirmed that each improvement technique has its own unique limitations. Specifically designed intervention or evaluation studies do yield valuable knowledge about a particular activity or intervention; however, the practical application can be challenging for clinical leadership. Eccles, Grimshaw, Walker, Johnston, and Pitts (2005) advocated using theory and theoretical frame- works to support the uptake of research findings in practice. Clinical leader- ship and mid-level management, however, seem less informed about implementation science and typically resort to practical approaches that are readily implemented to improve specific care delivery. Many clinical improvement projects have been informed by the availability of sample proj- ects and successful approaches provided by organizations such as the Institute for Healthcare Improvement (IHI; www.ihi.org). However, regulatory or accreditation related improvements have provided an important impetus for specific practices, such as The Joint Commission (2009) core measures and the use of aspirin for patients with an acute myocardial infarction (AMI). Implementation of these practices has been credited with improved outcomes (http://www.qualitymeasures.ahrq.gov/content.aspx?id=46434). Although such samples of successful implementation are available, recent evaluation (Robert Wood Johnson Foundation, 2011) of the Institute of Medicine (IOM; 2000, 2001) goals demonstrated that after a decade of quality improvement efforts, little substantive improvement has been made. The QIE model was specifically developed to address the lack of theoretically derived implemen- tation models that guide and support clinical leadership with the implementa- tion of organizational structures (features) that result in the anticipated processes of care and lead to performance improvement.

Conceptual Framework

One of the most established frameworks or models for the clinical setting is Donabedian’s (1966, 1988) Structure–Process–Outcomes model. Donabedian proposed a model for evaluating quality of care through the assessment of structure, process, and outcome; this model has provided an oft-used refer- ence for health services research and for clinical leadership as an organizing framework. Quality improvement (QI) initiatives have used Donabedian’s framework (Upenieks & Abelew, 2006) to direct specific activities. Mitchell, Ferketich, and Jennings (1998) further developed Donabedian’s model by adding the importance of context and culture for implementation efforts. Mitchell and Lang (2004) summarized the utilization of this modified model

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for implementation studies but noted the limited use of the model for practice improvement work.

A number of studies have evaluated the relationship between structural components of an organization, such as staffing, resources, and patient out- comes. The most common studies pertain to the use of nurse staffing levels and patient outcomes (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002; Talsma, Jones, Guo, Wilson, & Campbell, 2013), although staffing alone may not be suffi- cient, as context is an important factor (Mitchell & Lang, 2004). Donabedian’s model is not only the most studied, it is also well known and understood by clinical leadership. Further operationalization of “structure” is the focus of the QIE model to guide and direct specific processes that will contribute to the implementation of sustainable improvements.

The QIE model was developed as a framework guiding health care profes- sionals with the implementation of improvement initiatives that contribute to improved quality and safe health care. The QIE model operationalizes the “structure” component and identifies the specific structural features to sup- port the health care delivery process. Donabedian defined structure as the physical facility, equipment, and human resources, as well as organizational characteristics and payment methods. For the QIE model, structure is opera- tionalized in four components: Policy, Patient Preparedness, Provider Competency, and Performance and Accountability. The QIE model aims to support clinical leadership implementing necessary structural components, such as implementation of a relevant policy or protocol, to support the evi- dence-based health care processes of care leading to improved outcomes.

QIE Model Operationalizes Structure

The importance of ascertaining appropriate structures to support desirable processes has been shown in a number of studies. Table 1 summarizes (select) studies that support the notion that improvements pertaining to structure con- tribute to implementation of health care delivery processes and subsequent outcomes. The O’Reilly, Talsma, VanRiper, Kheterpal, and Burney (2006) and Wahl and colleagues (2006) studies present examples where specific struc- tures were implemented (daily clinical feedback reporting structure) and con- tributed to better processes (e.g., timely prophylactic antibiotics and following ventilator associated pneumonia [VAP] prevention protocols). Both systems were implemented in 2003-2005 and to date, still exist and continue to serve an important role in providing feedback about health care delivery processes). The interventions and associated processes (delivery of prophylactic antibiot- ics, specific VAP prevention protocols) were clearly communicated and used

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Table 1. List of Factors Influencing Adoption Implementation Science.

Author Factors

Hughes (2008) Strategies to guide quality improvement: a. Strong leadership b. Culture of safety and improvement c. Stakeholders involved d. Multi-disciplinary team that works closely

together e. Understanding the problem and root causes f. Use a proven, methodologically sound approach g. Standardizing care and processes h. Evidence-based practice i. Flexible implementation plan j. Improving quality of care can have multiple

purposes k. Appropriate use of technology l. Sufficient resources m. Continually collect and analyze data and

communicate results n. Stay focused and persevere

Caldwell, Chatman, O’Reilly, Ormiston, and Lapiz (2008)

Factors that affect implementation changes: a. Group norms b. Leader action c. Social control in organization

Carlfjord, Lindberg, Bendtsen, Nilsen, and Andersson (2010)

Factors that influence adoption process for health care changes:

a. Positive expectations at the unit b. Perceptions of the innovation being

compatible with existing routines and perceived advantages

Scott, Plotnikoff, Karunamuni, Bize, and Rodgers (2008)

Factors identified for adopting an innovation: a. Intention to use b. Relative advantage c. Years of experience

Bussières, Patey, Francis, Sales, and Grimshaw (2012)

Chiropractor study, identified five theoretical domains for adopting new guidelines:

a. Beliefs about consequences b. Social/professional role and identity c. Social influences d. Beliefs about capabilities e. Knowledge

(continued)

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Author Factors

Rycroft-Malone et al. (2002)

Implementation evidence to practice will realize success when:

a. Evidence (research, clinical experience, and patient experience) is well conceived, designed, and executed and there is consensus about it.

b. The context in which the evidence is being implemented is characterized by clarity of roles, decentralized decision making, transformational leadership, and a reliance on multiple sources of information on performance.

c. Facilitation mechanisms appropriate to the needs of the situation have been implemented.

Lee, Choi, Kang, Cho, and Chae (2002)

Assessment of factors influencing continuous quality improvement:

a. Use of scientific abilities in decision making b. Implementation of quality information system

capable of producing reliable information Kaplan et al. (2010) Context/influences on quality improvement success

in health care: a. Senior management leadership b. Organizational culture c. Data infrastructure and information systems d. Time involved in quality improvement e. Medical doctor involvement in quality

improvement f. Microsystem motivation to change g. Resources for quality improvement h. Quality improvement team leadership

Gurses et al. (2010) Identified factors affecting clinicians’ compliance with evidence-based guidelines:

a. Clinician characteristics b. Guideline characteristics c. System characteristics d. Implementation characteristics

Table 1. (continued)

by staff. A more diffuse improvement target, such as reducing pressure ulcers, demonstrated a similar response, although the system did not sustain itself as well. The intervention mirrors those of the O’Reilly et al. (2006) and Wahl et al. (2006) studies by implementing a daily pressure ulcer risk feedback sys- tem; however, the subsequent processes of care are less specific. This

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sampling of studies confirms the importance of “structure” and its support in the implementation of improvement activities.

Four QIE Model Components

The QIE Model includes four components: Policy, Patient Preparedness, Provider Competency, and Performance and Accountability. The components serve to guide the users of the model to determine whether all components pertaining to the specific quality improvement goal have been reached. Definitions of these components are provided below.

Policy refers to the various policies, guidelines, or protocols that are in place to communicate the standard of practice for a particular condition and/ or patient characteristics. Typically, evidence-based literature is reviewed and aligned with hospital policy. The “Policy” component is used to present the organizational context and direction from (clinical) leadership. Implementing or reviewing current Policy typically requires that existing documentation is reviewed, discussed with multiple stakeholders, and modi- fied to reflect the (new) best practice (IOM, 2011).

Patient Preparedness is the component that reminds the user to specifi- cally identify the implementation activities needed to ascertain that patients and family also receive pertinent preparation or care in support of the quality initiative that is being pursued. The essence of this component is to inform and educate patients and family members about specific activities in support of the quality goals (Carayon et al., 2006; Zineldin, 2006).

Provider Competency describes the set of activities a health care organiza- tion engages in to assure that its workforce is prepared, competent, trained, and safe to deliver care. Aside from basic training of clinical staff, health care organizations are responsible for communicating specific care delivery pro- tocols and ascertaining that the clinical staff are appropriately prepared to deliver the care according to protocol. Provider competency includes both the educational training and confirmation that the provider is competent to per- form a particular activity (Beach et al., 2005; Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003).

Performance and Accountability describes the initiatives of a health sys- tem to assess its own performance and to hold staff and leadership account- able for performance that does not meet the expectations. Typically, this includes some verification or reporting system to assess, monitor, and evalu- ate whether the health system delivers the care safely, efficiently, effectively, and in a patient centered manner. This QIE model component provides the feedback about adherence to a particular evidence-based practice and is used to determine whether implementation efforts are successful or require further attention (Murray & Frenk, 2000).

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The four QIE components are related but not dependent on each other. Pending the quality goal and the current status of a component of the quality goal, one component may receive more focus and attention than another component. For example, a practice that is well established in policies and protocols may not require a full review and revision of the policy. Patient preparedness may not be invoked when the activity cannot be influenced by patient activity, for instance, an improvement project pertaining to specimen processing. The provider competence and performance and accountability components will be invoked with all quality goals and associated projects. Based on the project, one or more of the QIE components may be lesser involved. The QIE model is aimed at mid-level directors and quality manag- ers who understand the local context and can influence the implementation of specific QI-related activities. The model does not include a step-by-step pro- cess to implement activities; however, probing questions pertaining to each component are provided to the user. The QIE model focuses on a range of implementation activities, understanding that rarely does this involve one person or profession; thus, the model is inherently multi-disciplinary and implies a team-based approach to quality improvement.

Evaluation of the QIE Model

To date, the QIE model has been partially evaluated. One component, “Policy,” related to the implementation of a recommended guideline was evaluated. In 2011, the National Quality Forum (NQF; 2010; www.qualityforum.org) rec- ommended the use of alcohol-based skin preparation agents prior to surgery to help reduce surgical site infections (SSI). The main difference in skin prep is whether it contains alcohol and whether its basis is derived from povidine iodine or chlorhexidine gluconate (CHG; Talsma, Galecki, Chenoweth, Geun, & Campbell, 2013). Results from a study prior to implementation of the NQF guideline indicated that less than half of all abdominal procedures received an alcohol-based skin prep (Talsma, Galecki, et al., 2013), suggesting perfor- mance improvement is indicated. The implementation of activities associated with the use of alcohol-based skin prep serves as a case study to evaluate the properties of components of the QIE model. The results of this study contrib- ute to establishing validity of the QIE model.

Method

The Perioperative Outcomes Initiative (POI; www.poi-cqi.org) is a Michigan hospital network, comprised of 17 hospitals at the time of the study. The net- work aims to improve perioperative care and uses hospital level data to deter- mine improvements have occurred.

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All participating Michigan hospitals were invited to submit a copy of their alcohol-based skin prep policy. Study staff reviewed all policies and com- pared each hospital’s policy with that of the American Perioperative Registered Nurses (AORN) Association guidelines (Conner, 2012). AORN guidelines were carefully reviewed, and a grid was designed highlighting components of the guidelines pertinent to study objectives. This grid was developed to standardize the process of identifying gaps in individual skin prep policies. Study staff then reviewed these components and mutually agreed on the component items for modification and inclusion in the final policy review grid (see Table 2). Each hospital’s policy was carefully reviewed for the inclusion of the AORN skin prep policy guidelines and appropriately evaluated for its accordance with these guidelines. Each hospi- tal received summaries identifying gaps in their policies along with practical summaries supporting interventions and modifications to address these gaps based on facility-specific resources. For example, multiple sites were quick to react, organizing staff in services on skin preparation whereas others modi- fied skin prep practices for patients in the preoperative area. Still others revised their policies, reflecting POI feedback.

Hospitals received feedback reports regarding the completeness and docu- mented values and were offered the opportunity to resubmit their data if needed. Subsequent data management and analytical methods led to the reporting of the alcohol-based skin prep rates for a random selection of abdominal cases of participating hospitals. The POI staff obtained self- reported information about the QI activities hospitals engaged in. Information about involvement in patient preparation implementation and provider com- petency program reviews was gathered from the bi-annual POI Tracking Form submissions and subsequent discussions with participating hospitals to confirm the information was current. The data focused on whether hospitals planned to or had initiated any activities pertaining to patient preparation or provider competency during the study time frame.

Results

Seventeen hospitals, participating in the POI collaborative were invited to participate in the QI project to increase adherence to alcohol-based skin preparation agents. All hospitals received literature about the use of alcohol- based skin prep agents (Darouiche et al., 2010; NQF, 2011; Talsma & Chenoweth, 2012) and were exposed to presentations and handout materials describing the four components of the QIE model (QIE “Star”), the POI QIE© Tracking Form, and a POI A3 presenting hospital specific and aggre- gate alcohol-based skin prep rates and SSI trends (Talsma, McLaughlin, Bathish, & Kuttner, 2013).

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Table 2. Skin Prep Policy Review Results.

Skin Prep Policy Item Item Included in No. of

Hospital Policies (n = 15)

Policy statement Written 11 Reviewed 10 Readily available 11 Policy purpose 10 Definitions 2 Surgical skin site area free of soil, debris, and

exudate 9

Minimize risk of surgical fire and patient burn 7 Documentation 7 Quality management program 0 Staff responsibilities 1 (“all surgical team members”) OR nurse 0 Surgical Tech 0 Surgeon 0 Other 0 Manufacturer recommendations for handling

skin prep agents available, reviewed, followed

7

Skin prep agent Application 9 Method 2 Pre-op shower 2 Hair removal 10 Antiseptic agent choice based on patient

assessment 9 (2 “surgeon preference”)

Prevention of skin and tissue injury from prolonged contact with skin prep agent

9

Skin prep agent 8 Procedures included in policy 8 Competency validation for staff 0 Skin prep agent selection 0 Application procedure 0 Patient assessment 0 Removal of skin prep agent after surgery 5

The data used for the study pertained to abdominal procedures (appendec- tomy, cholecystectomy, colectomy, enterectomy, and hernia) and the use of skin preparation agents. All hospital data are obtained from electronic medical

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records (EMR) data and securely uploaded to the POI server, located within the university information technology (IT) environment. Data quality assurance processes include the POI Data Validation Report© hospital staff use to review and correct missing data and mapping issues. Fifteen (out of 17) hospitals have submitted data on a quarterly basis and have received descriptive reports.

Two (out of 17) hospitals declined participation in this particular QI proj- ect. One hospital already had implemented this guideline, and their perfor- mance was consistently greater than 80%. The other hospital declined as challenges with data submissions at the time precluded the ability to monitor performance. A total of 15 hospitals participated in this study.

The response rate to address this research question was adequate as 11 of 15 (73.3%) hospitals submitted policies for review and analyses. POI staff compared the submitted hospital policy components with the AORN “Recommended Practices for Perioperative Patient Skin Antisepsis” (Conner, 2013). Hospitals received written feedback, and if requested, sample lan- guage to address gaps in current policies (Talsma, McLaughlin, et al., 2013). Review of POI QIE Tracking Forms and personal follow-up by POI staff confirmed whether updates or modifications to skin prep policies were made. Hospitals that did provide a policy for review (n = 11) showed an increase from 61.8% (Q12 2011) in alcohol-based skin prep use to 71.7% (Q34 2012; p < .01) over the study time frame. The four hospitals that did not submit a policy for review failed to demonstrate improvement, falling from 39.5% (Q12 2011) to 37.1% (Q34 2012) with the skin prep policy.

Subsequent analyses focused on whether the 11 hospitals that provided a policy for review were related to the process of modifying internal hospital policy. Analyses indicated that 7 (7/11, 63.6%) hospitals did review and mod- ify their internal skin prep policy, 4 (4/11) hospitals reviewed but did not modify their skin prep policy. Figure 1 demonstrates that hospitals that did

Figure 1. Alcohol-based skin prep rates by policy revision.

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review and modify their skin prep policy increased their use of alcohol-based skin prep from 59.3% (Q12 2011) to 63.2% (Q34 2012; p < .01), a 7.5% increase. Hospitals that reviewed their policy but did not modify their policy, interestingly, already demonstrated a higher adherence (76.2%) at the begin- ning of the study (Q12 2011) and increased to 83.4% (Q34 2012) by the end of the study time frame, reflecting a 9.5% increase in alcohol-based skin prep use. In sum, the focus on policy review contributed to a significant improve- ment in use of alcohol-based skin prep use for hospitals that participated in this QI project. We observed that hospitals with an existing policy in place demonstrated a higher beginning adherence rate (76.2%) and also increased more (9.5% vs. 7.5%) than those that did not have such a policy in place. However, hospitals that did not participate in this QI project did not demon- strate improved alcohol-based skin prep use.

The four components of the QIE model including “Policy,” “Patient Preparedness,” “Provider Competency,” and “Performance and Accountability” will be evaluated with respect to their contribution to the QI activities.

Policy

Hospitals were informed that “Policy” is an umbrella term that includes guidelines, protocols, orders, and so on; however, it is a structural agreement regarding a particular practice. Initially, hospitals displayed little interest to review their policy. The provision of a review according to national (AORN) guidelines and quarterly performance report demonstrating gaps in perfor- mance contributed to hospital level engagement in this activity. Submission of an A3 and POI Tracking Log, where hospital contacts documented their project activity, served to pursue necessary modifications. Initial analyses indicated policy updates were made following the review and feedback to POI hospital contacts.

Patient Preparedness

The collaborative presented a conference call and engaged in discussion with Operating Room (OR) directors about the importance of patient/family pre- paredness regarding surgery. Examples of hospitals that had implemented such programs were provided, contributing to the exchange of expertise between hospitals. At this time, three hospitals have initiated a specific patient preparation program providing cleansing materials, special education, and reminders about basic patient hygiene and cleanliness. One hospital reported that the pre-op nurses who call patients the day before a procedure had developed a new phone protocol emphasizing skin preparation. Although

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specific results were not available at the time this article was developed, pre- liminary results suggested that hospitals made modifications to improve on internal patient education approaches and content.

Provider Competency

Discussion with the 17 hospitals demonstrated wide variation in practices to ascertain providers were competent in applying skin prep agents. Variation was noted regarding whether students, residents, or fellows were fully trained by the specific hospital or were trained prior to working in that hospital. Hospitals varied about providing annual refresher courses for all staff, relationships with particular surgeons regarding their skin preps, and whether training is con- ducted in house or by a product related representative. Participating hospitals not only indicated a need to standardize their Provider Competency program but also recognized potential challenges associated with modifying such pro- grams. This particular sub-component demonstrated the greatest variation and least agreement between the participating hospitals, suggesting further research may be indicated to understand optimum performance.

Performance and Accountability

All hospitals in the project received feedback and reports about the use of alcohol-based skin prep and SSI on a quarterly basis. The reports are reviewed and discussed at quarterly meetings, during clinical seminars, and OR director’s meeting. Please note that for this preliminary sample, the hospitals without policy review did not demonstrate an improvement in adherence to alcohol-based skin prep agents (Talsma, McLaughlin, et al., 2013). Although providing feedback and reports is necessary to moni- tor progress, hospital level reports alone may not be sufficient to initiate improvement.

In sum, review of the four components allowed hospitals to assess all aspects of the QI activity and served both as guidance of local QI programs and as a reminder to implement comprehensive patient care activities. The Policy component contributed much to the improvement of using alcohol- based skin prep agents. The feedback from POI staff (using AORN guide- lines) about particular policy components may have contributed to internal review and modification of a policy. The Patient Preparation component enjoyed varying levels of implementation, and hospitals responded favorably to the review of current practices. The Provider Competency component appeared to be least changed, which was attributed to the complexity of mod- ifying such practices.

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Discussion

This study evaluated the QIE model and its sub-components in a 17-hospital network. Results indicate that the components of the model contributed to improvement in implementation of evidence-based practice. The initial focus on reviewing existing policies and quarterly reporting combined with perfor- mance feedback helped local clinical leaders in their improvement efforts, although reporting alone was not sufficient to leverage improvement for hos- pitals that had low performance or did not participate in the policy review process. The support and guidance from the study center were also appreci- ated by the participating hospitals, thus, the independent effect of the QIE model should be further determined in a study environment without regular contacts and a supporting collaborative environment.

Various useful models have been applied to inform evidence-based prac- tice processes. Such models identify steps required to pinpoint, research, plan, and follow-up on QI interventions. The QIE model proposes to build on essential structural components common to any health care episode. This new structure-based model for facilitating implementation of better care practices is simple, practical, and current. The QIE model supports hospitals seeking to implement appropriate, sustainable QI interventions as it builds on existing organizational arrangements rather than redirecting specific pro- cesses without structural support in place.

The four components (Policy, Patient Preparedness, Provider Competency, Performance and Accountability) are readily understood by clinical leadership and staff. The model does not prescribe processes; however, it indicates appro- priate structures that provide the foundation for specific processes. This approach allows staff to “build-in” a particular practice change, much like the structural changes made to facilitate the delivery of timely prophylactic antibiotics Surgical Care Improvement Project (SCIP)-1; O’Reilly et al., 2006; Talsma, Tschannen, Ying, & Kazemi, 2011; Wahl et al., 2006). The flexibility inherent to the model allows for implementation in local clinical settings that are sensitive to context and cultures. The QIE model offers an approach for implementation of QI activ- ities. It identifies four sub-components to be addressed but does not include specific implementation steps as every hospital environment and context will differ (Mitchell & Lang, 2004). Feedback from the users, 15 OR directors in Michigan, supported the fact that identification of main issues was important, as processes differ for each hospital and each situation, in essence, confirming the Mitchell and Lang (2004) model that emphasizes the importance of work envi- ronment and context. Future steps include the testing of all components of the model and determining the key concepts contained in each component.

The QIE model provides a framework for implementation of activities that contribute to improved adherence of an evidence-based practice. The four

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components of the framework allow for a comprehensive review of clinical activities that contribute to successful health care delivery processes, culmi- nating in the improved adherence to an evidence-based practice. The model contributed to the successful implementation of this practice and proved very helpful in communicating with OR directors and other clinical leadership.

Limitations of this initial study include the self-selection of hospitals and the lack of randomization to receive the QIE model and subsequent interventions. The total sample of participating hospitals was small; however, results provide initial support and validation for the model. Other conditions may have affected the degree to which hospitals adopted feedback recommendations, for exam- ple, available staff and budget for supplies, and individual motivation, all of which may affect implementation of recommended practices. Future studies should evaluate the impact of specific components as well as engage in discus- sion with mid-level management about implementation activities.

Authors’ Note

We used Perioperative Outcomes Initiative (POI) data for the purposes of the study.

Acknowledgments

Support for the preparation of this article by Ms. K. McIlroy and Ms. R. Sirichorachai is greatly appreciated.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors gratefully acknowledge funding from BlueCross BlueShield of Michigan/BlueCare Network for their support of the Perioperative Outcomes Initiative (POI; www.poi.cqi.org) through the Value Partnerships Program (www.valuepartnerships.com).

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