CP Week 6 Discussion
lisaberdinassi33
EBP_Step_by_Step_08copy.pdf
Following the Evidence: Planning for Sustainable Change The EBP team makes plans to implement an RRT in their hospital.
This is the eighth article in a series from the Arizona State University College of Nursing and Health Innovation’s Cen- ter for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational cul- ture, the highest quality of care and best patient outcomes can be achieved.
The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every other month to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we’ve scheduled “Chat with the Authors” calls every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the next call will be published with May’s Evidence-Based Practice, Step by Step.
After the evidence-based practice (EBP) team of Rebecca R., Carlos A., and Chen M. synthesized and appraised the evidence they found to answer their clinical question, they concluded that rapid re- sponse teams (RRTs) were effec- tive in reducing both code rates outside the ICU (CRO) and non- ICU mortality (NIM), excluding patients with do not resuscitate (DNR) orders (see “Clinical Ap- praisal of the Evidence: Part III,” November 2010). They also de- cided that a reduction in un- planned ICU admissions (UICUA) may be a reasonable outcome to expect. In addition, they chose the members of their RRT: an advanced practice nurse, a phy- sician, an ICU staff nurse, a respi- ratory therapist, and a chaplain.
The team’s next step is to de- velop a plan to implement an RRT in their hospital. They be gin by planning how to collect baseline data on their chosen outcomes so they can evaluate the RRT’s impact on those outcomes. Carlos explains to the team that measuring out- comes, typically before and after implementing an intervention, is
essential to documenting the im- pact of the EBP implementation project on health care quality and/ or patient outcomes.1 Rebecca adds that they’ll also need to con- sider cost as an outcome and must plan for how to capture the costs of the RRT as well as evaluate the cost savings for positive changes in CRO, NIM, and UICUA.
THE IMPLEMENTATION PLAN Rebecca and Chen are excited about the plan to implement an RRT in their hospital and tell Carlos how much they appreci- ate his ongoing support. Carlos checks in often with the team now that the project is under way. His experience as an expert EBP mentor has taught him the importance of assessing the team’s progress at frequent intervals to see how he can support them.
To help the team develop a detailed plan for implementing an RRT in their hospital, Car- los pro vides them with an EBP Implementation Plan template that he used in his EBP Gradu - ate Certificate Program (Figure 1). This plan was developed using the Advancing Research and
Clin i cal Practice Through Close Collaboration (ARCC) model, in which EBP mentors are key fa cilitators of sustainable change. Carlos explains that even though they now have a template to guide them in the process, EBP implementation can be unpre- dictable. The team cannot antic- ipate all of the challenges or or- ganizational nuances they may encounter in launching an RRT in their hospital.
Preliminary checkpoint catch- up. The team reviews the template, beginning with the Preliminary Checkpoint, to determine which steps they’ve already taken and which they’ll need to prepare for going forward. They’ve al- ready completed checkpoints one through four, but two steps in the preliminary checkpoint still need to be addressed: identifying key stake- holders and acquiring approval from the internal review board (IRB; sometimes called the ethics review board, or the human sub- jects or ethics committee). The team members discuss their roles in the project and agree that these may evolve as the implementation plan develops.
54 AJN ▼ January 2011 ▼ Vol. 111, No. 1 ajnonline.com
By Ellen Fineout - O verholt, PhD, RN, FNAP, FAAN, Kathleen M. Williamson, PhD, RN, Lynn
Gallagher-Ford, RN, MSN, NE-BC, Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP,
FAAN, and Susan B. Stillwell, DNP, RN, CNE
Key stakeholders. Carlos tells Rebecca and Chen that consider- ing who would be stakeholders in a project—in this case, those individuals or groups that may be affected by or can influence the implementation of an RRT—is a step that’s often overlooked. He explains that active stakeholders are those people who have a key role in making the project happen. Passive stakeholders are those who may not be actively involved in the project but who could promote or stymie its success. Carlos ad- vises the team to consider all po- tential stakeholders, as theirs is an organization-wide project and some stakeholders may not be ob- vious. He asks Rebecca and Chen to think about the outcomes of the project and to which stake- holders throughout the hospital they’d be important. The team discusses that, as staff nurses, they don’t always think about their work from an organizational standpoint. Carlos says that thinking about the project in an organization-wide context will help them figure out who needs to be on the team. He provides examples of stakeholders who would not only be critical to the RRT process but who might also have connections that could be important to the project’s success. For example, connecting with key councils (practice, quality, criti cal care) or work groups (education, communications) may provide ac - cess to already- established pro- cesses for introduc ing a policy into the organization.
The team preliminarily identifies the members of their RRT, patients, staff nurses, and administrators as active stakeholders. They identify the finance, risk management, and education departments, mid- level managers, and the chief ex- ecutive and chief nursing officers as potential passive stakeholders.
The team agrees that although these may not be all of the stake- holders—more may be identified as planning continues—they’re likely key players who need to be included in the implementation plan for now. Carlos tells the team that it’s important to keep thinking about who will impact the project and whom the project will impact, so that everyone who needs to be on board with the plan is brought on early.
IRB approval. Carlos explains that an IRB is charged with mak- ing sure that subjects involved in a research study are safe and that the research is conducted in such a way that the findings are applicable to a broader popula- tion than just those in the study, which is known as generalizabil ity.2 The team discusses whether they need to submit their imple- men tation plan to their hospital’s IRB for approval, since they’re not conducting research. Al- though they’ll be collecting out- comes data to evaluate whether they’re achiev ing the expected outcomes cited in the literature, their evidence-based RRT inter- vention is a best practice improve- ment project, not a research study. Still, Car los stresses that the team has an obligation to publish how their evidence-based intervention works in their hospital. He re minds them that the seventh step in the EBP process is to disseminate re- sults so others can learn how a project was implemented and eval - uated (the process) and whether the out comes identified in the lit- erature were obtained (the pro ject outcomes, or end points) (see “The Seven Steps of Evidence- Based Practice,” January 2010). Car los tells Rebecca and Chen that if they’re going to publish their pro ject, they’ll need to submit their implementation plan for IRB approval. Moreover, they
cannot collect their baseline data without prior IRB approval. The team dis cusses that when they write up their project, they can address some of the issues they had with the reporting of implementa- tion projects in the literature, such as how differences in the format- ting of these reports makes it hard to synthesize the data (see “Clini- cal Appraisal of the Evidence: Part III,” November 2010). For these reasons, the team feels it’s essen- tial that they publish their project, so they’ll pursue IRB approval.
Before the team begins writ- ing up their implementation plan (which they will reformulate as an IRB proposal), they discuss an essential assumption they hold, which is that all patients who enter a hospital sign a “consent for treatment” expecting clinicians and others caring for them to pro- vide the best care possible. Al- though patients may not re fer to their care as evidencebased prac tice, the EBP team feels strongly that patients’ expectations reflect professional practice in which daily decisions are made based on the best evidence available. With this expectation and their decision to publish the project in mind, the team discusses that the outcomes data will be used in a way that wasn’t covered in the consent for treatment. Thus, the IRB review of their proposal should reveal any ways in which publishing the outcomes of the project could put recipients of the practice change at risk. In effect, the IRB would be reviewing the plan to make sure that the data from those patients
Considering who would be stakeholders in a project is a step that’s often overlooked.
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Fi gu
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56 AJN ▼ January 2011 ▼ Vol. 111, No. 1 ajnonline.com
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[email protected] AJN ▼ January 2011 ▼ Vol. 111, No. 1 57
who receive the intervention will be treated confidentially.
The team discusses that their RRT intervention is supported by studies of RRTs that were sub- mitted to and approved by their respective IRBs; that the IRB ap- prov als of these RRT projects lends confidence to their intervention. Rebecca and Chen know it’s im- portant that their plan be reviewed, but they express concern about how to engage the IRB process. Carlos tells them that the IRB has several forms available to assist clinicians and researchers in pin- pointing those aspects of their
study or project that may increase risk of any kind to the people in- volved. The team seeks out more information on their hospital’s Web site and finds the appropriate form for an implementation proj- ect. They agree to complete the form together as they develop their implementation plan.
Checkpoint five and for ward. As the team moves on to Check- point Five in the EBP Implemen- tation Plan template, Carlos talks to them about the critical impor- tance of defining the purpose of the project.
Purpose of the project. A clearly defined purpose sets the entire plan ning process in motion, Car- los says; it’s the touchstone of the project that the team can return to periodically to ensure they’re on course. The team agrees that the purpose of their project is to im plement and evaluate the effective ness of an RRT in their hospital.
Baseline data collection. Car- los tells the team that collecting data prior to implementation of the RRT is important because it will help determine the extent of any already existing problems as well as enable the evaluation of the project outcomes.3 He ex- plains that various data are gen- erated within the hospital, which he calls internal evidence. The sources for these data are in vari- ous locations and are referred to in a variety of ways, such as: qual- ity management, risk management, finance, and human resources de- partments; clinical systems; oper- ational systems; and electronic medical records/information tech- nology (see Table 1). Carlos tells the team that internal evidence that’s collected for federal and state agencies or for regulatory and specialty organizations, such as the American Nurses Creden- tialing Center’s Magnet Recogni- tion Program, can also be used as outcomes. As an example, he pro- vides reports from their hospital’s quality commit tee that include
data for CRO, UICUA, and over- all hospital mor tality. Chen asks what it will require to get data only for NIM. Carlos replies that he’ll have to find out which depart- ment in the hospital creates qual- ity committee reports and ask if NIM data can be culled from the overall hospital mortality data. He explains that there are many data repository systems within the hospital and that each system may collect different data and may require a different way of request- ing those data. Carlos helps the team understand that obtaining data may be complicated at times, but one’s success greatly de pends on knowing whom to ask.
To help the team capture the out comes data they’ll need to ob- tain at baseline and again after the project, Carlos recommends they work with the information tech- nology and finance departments. Chen asks if putting the outcomes in a chart would help to clearly outline the “who, what, when, where, and how” of baseline data collection. The team agrees that this would help them understand the financial outcomes (sometimes referred to as the busi ness case), the process and structure of the project,4 and the patient outcomes that will be measured at the end of the project (see Table 2).
The process. The team discus- ses how to ensure that the pro- cess of implementing an RRT in their hospital goes well. Rebecca reminds the team about their and the MERIT trial authors’ obser- vations on how the MERIT trial was conducted, particularly on how the RRT protocol was imple- mented.5 (The control hospitals’ code teams may have functioned as RRTs, which could explain why there was no difference be- tween the control group and the intervention group; see “Critical Appraisal of the Evidence, Part II,” September 2010). She asks the group for ideas about how they can collect data on the process of
Table 1. Potential Sources and Types of Internal Evidence
Source of Data Type of Data
Quality Management
Hospital quality indicators Nursing quality indicators Patient satisfaction Regulatory/accreditation requirements
Risk Management
Incident reporting Medication errors Sentinel events Patient complaints
Finance Admission, transfer, and discharge data Billing and coding, capital and operation budgets Medicare-severity diagnosis- related groups (MS-DRGs) Cost and return on investment data
Clinical Systems
Monitoring devices and equipment
Operational Systems
Patient tracking and flow Staffing and scheduling
Electronic Med ical Records/ Information Technology
Patient history Patient assessment Diagnostic test results Medication regime Plan of care
Data collected, submitted to and bench- marked with outside sources
National Database of Nursing Quality Indicators Centers for Medicare and Medicaid Services Patient satisfaction survey organizations
58 AJN ▼ January 2011 ▼ Vol. 111, No. 1 ajnonline.com
implementing the RRT to dem- onstrate that they have done it well. Carlos says that how well they implement the intervention is called the fidelity of the inter vention. He recommends keeping good notes on the work being done. They talk about the need to develop a project data collec- tion tool that staff can use when calling the RRT. Chen volunteers
to develop this form, using simi- lar forms in the literature they re- viewed as a basis. Carlos suggests that maybe Chen should see if anything new has been published, since it’s been a few months since they completed their literature search.
The team talks about the im- portance of measuring the costs and benefits of the RRT, especially
its benefits divided by the costs, which Carlos notes is called its return on investment (ROI). Car- los suggests that the team meet with the finance department to dis cuss their plan to measure the costs and ROI of an RRT. Re- becca volunteers to be responsi- ble for ob tain ing the finan cial data and requests that Carlos be available for support, if needed,
Table 2: Considerations in Measuring Outcomes for the RRT Implementation Project
Making the Case Data Needed for an RRT Processes/Outcomes to Be Measured
The strategic case: Evaluate project in relation to its impact (high volume, high risk, high cost) and the strategic priori- ties of the organization (business plan, accreditation, reimbursement, licensing)
Hospital strategic plan; CRO, UICUA, and NIM data; and expected targets for these data, if identified
• CRO, UICUA, and NIM before (and after) implementing a system-wide RRT
The business case (financial outcomes): Calculate net return on investment—for example, cost of project minus cost off- set by reducing identified outcomes
Actual cost assessed for supplies, staff education, RRT members providing the ser- vice, other infrastructure for the RRT team (special process for calling an RRT, for example), identified outcomes
• Cost savings from prevention of CRO, UICUA, and NIM before (and after) imple- menting a system-wide RRT
The resources case (assess/ identify resources needed to achieve outcomes):
Infrastructure: Policies, procedures, documentation systems, and data- reporting processes
Supplies: New equipment or supplies needed for the project
Human resources: Identify departments that will be supporting the project (such as, nursing, respiratory, physi- cians, information systems, purchas- ing, education, pastoral care)
Identification of:
Policy for how to activate RRT: • Define who will write policy • List committees needed to approve policy • List processes for rolling out new policy
Equipment required for early intervention care
Human resources support for hiring per- sonnel to fill RRT roles or to backfill posi- tions vacated to fill RRT
• Policies and protocols developed to facilitate RRT
• Documentation systems adjusted to accommodate RRT record
• Electronic data reporting available to capture RRT process and outcome
• Redo code cart to add RRT box contain- ing supplies/equipment that may expedite early intervention care
• RRT members evaluation of their role
Process measures to achieve outcomes (sometimes called process outcomes): Staff education plan, project data col- lection, staff and family feedback
Staff education plan RRT project data collection tool Staff feedback tool Family feedback tool
• Staff education completion rates • Quality of RRT project events, such as how
RRT protocol was followed • Effectiveness of RRT project events • Timeliness of project events, such as time
frame from call to RRT arrival • Family and staff response to how RRT is
delivered (the intervention protocol) • Outcomes of each RRT call
CRO = code rates outside the ICU; NIM = non-ICU mortality; RRT = rapid response team; UICUA = unplanned ICU admissions.
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to which he read ily agrees. Chen agrees to work with Carlos to en- sure that data on CRO, UICUA, and NIM are systematically col- lected and to focus on the process outcomes (how well the RRT pro- ject is implemented). For example, if there was a breach in protocol implementation—in how well the RRT protocol was delivered to the active stakeholders, for in- stance—that breach could lead to an outcome that was different from what was expected. This un- expected outcome may not be be- cause the RRT intervention didn’t work, but because of a glitch in the process: the RRT pro tocol wasn’t delivered as planned.
As work on the project is plan- ned and discussed, the roles of the team naturally begin to fall into place. As part of formulating the implementation plan, they discuss what questions about data collec- tion they’ll need to ask in order to measure their outcomes of CRO, UICUA, and NIM (see Questions to Ask in Preparation for Data Collection). Carlos reflects back on the definitions and measures the team discussed in their appraisal of the evidence and how the dif- ferent definitions of mortality
(whether it included DNR cases, for example) led to some confusion about comparing the impact of an RRT on that variable (see “Criti- cal Appraisal of the Evi dence: Part II,” September 2010). He explains the importance of how the data are measured (what mechanisms are used, for example, and why and how to know they’re good methods for measuring the data). He says that in order to determine the impact of an EBP project such as the implementation of an RRT, the data must be measurable (able to be counted), accessible (the team has access to the data), and user friendly (understandable and able to be used without difficulty). Chen and Rebecca decide they want to create a data collection plan that meets all of these criteria. With the questions on data collec- tion to guide them, they realize that multiple disciplines within the hospital (not only nursing) will be involved in helping to collect the baseline data for the pro ject.
From the team’s discussion, Rebecca and Chen put together a preliminary plan for evaluating the RRT project, keeping the fol- lowing key areas in mind: the stra- tegic case, business case, resources
case, and process measures (see Table 2). They also add the fol- low ing process outcomes to their plan: the number of staff edu- cated on the RRT, the number of RRT calls, the primary rea- sons for calling an RRT, and fam- ily and staff satisfaction with the RRT process.
In the March column, join Rebecca, Chen, and Carlos as they move through the next sev- eral steps of the EBP implementa- tion process, including identifying and planning for the barriers they may encounter as the EBP change is rolled out, as well as providing system-wide education on the in- tended use and expected outcomes of an RRT. ▼
Ellen FineoutOverholt is clinical pro fessor and director of the Center for the Advancement of EvidenceBased Practice (CAEP) at Arizona State University in Phoenix, where Lynn GallagherFord is assistant director, Susan B. Stillwell is associate director, and Bernadette Mazurek Melnyk is dean and distin guished foundation professor of nursing at the College of Nursing and Health Innovation. Kathleen M. Williamson is former associate director of the CAEP. Contact author: Ellen FineoutOverholt, ellen.fineout[email protected].
REFERENCES 1. Fineout-Overholt E, Johnston L.
Teaching EBP: Implementation of evidence: moving from the evidence to action. Worldviews Evid Based Nurs 2006;3(4):194-200.
2. Department of Health and Human Services. 45 CFR 46.101 Public wel- fare. Protection of human subjects; 2009. http://www.hhs.gov/ohrp/ humansubjects/guidance/45cfr46. htm#46.101.
3. Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson K. Trans- forming healthcare quality through innovations in evidence-based prac- tice. In: Porter-O’Grady T, Malloch K, editors. Innovation leadership: creating the landscape of health care. 2nd ed. Sudbury, MA: Jones and Bartlett; 2010. p. 167-94.
4. Wyszewianski L. Basic concepts of healthcare quality. In: Ransom ER, et al., editors. The healthcare quality book. 2nd ed. Chicago: Health Administration Press; 2008. p. 25-42.
5. Hillman K, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised con- trolled trial. Lancet 2005;365: 2091-7.
Questions to Ask in Preparation for Data Collection • How are the outcomes defined? • What data will be used to measure the outcomes? • Who “owns” the data needed for this project? • Who will (or already does) generate the data needed for the
project? • What special clearances are required to access the data? • What are the restrictions for sharing these data? • Who will be responsible for collecting the data? • When will the data be collected? • Where are the data located in the hospital? • How will the evidence-based practice (EBP) team access the
data? • How will the EBP team store the data? • What program will the EBP team use to analyze the data? • Who will help the EBP team with data analysis? • How will the EBP team manage the data (data entry, cleaning,
labeling)?
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