EBP and the Theory-Practice Gap

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 Center 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 culture, 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. A fter 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 response teams (RRTs) were effective in reducing both code rates outside the ICU (CRO) and nonICU mortality (NIM), excluding patients with do not resuscitate (DNR) orders (see “Clinical Appraisal of the Evidence: Part III,” November 2010). They also decided that a reduction in unplanned 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 be­gin 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 outcomes, typically before and after implementing an intervention, is 54 AJN ▼ January 2011 ▼ Vol. 111, No. 1 essential to documenting the impact of the EBP implementation project on health care quality and/ or patient outcomes.1 Rebecca adds that they’ll also need to consider 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, Carlos pro­vides 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 Clin­­i­cal Practice Through Close Collaboration (ARCC) model, in which EBP mentors are key ­fa­cilitators of sustainable change. Carlos explains that even though they now have a template to guide them in the process, EBP implementation can be unpredictable. The team cannot antic­ ipate all of the challenges or organizational nuances they may encounter in launching an RRT in their hospital. Preliminary checkpoint catch­up. 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 already 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 subjects or ethics committee). The team members discuss their roles in the project and agree that these may evolve ­as the implementation plan develops. ajnonline.com By Ellen Fineout-Overholt, 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 considering 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 advises the team to consider all potential 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 stakeholders 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, criti­cal care) or work groups (education, communications) may provide ac­­ cess to already-­established processes for introduc­ing a policy into the organization. EBP and the Theory-Practice Gap

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, midlevel managers, and the chief executive and chief nursing officers as potential passive stakeholders. ajn@wolterskluwer.com The team agrees that although these may not be all of the stakeholders—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 making 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 population than just those in the study, which ­is known as generalizabil­ ity.2 ­The team discusses whether they need to submit their imple­ men­tation plan to their hospital’s IRB for approval, since they’re not ­conducting research. Although they’ll be collecting outcomes data to evaluate whether they’re achiev­ing the expected outcomes cited in the literature, their evidence-based RRT intervention is a best practice improve­ ment project, ­not a research study. Still, Car­los stresses that the team has an ­obligation to publish how their ­evidence-based intervention works in their hospital. He re­minds them that the seventh step in the EBP process is to disseminate results so others can learn how a project was implemented and eval­­ uated (the process) and whether the out­comes identified in the literature were obtained (the pro­ ject outcomes, or end points) (see “The Seven Steps of EvidenceBased Practice,” January 2010). Car­­los tells Rebecca and Chen that if they’re going to publish their pro­ject, they’ll need to submit their implementation plan for IRB approval. Moreover, they cannot collect their baseline data without prior IRB approval. The team dis­cusses 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 formatting of these reports makes it hard to synthesize the data (see “Clinical Appraisal of the Evidence: Part III,” November 2010). For these reasons, the team feels it’s essential that they publish their project, so they’ll pursue IRB approval. Considering who would be stakeholders in a project is a step that’s often overlooked. EBP and the Theory-Practice Gap

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. Although patients may not re­fer to their care as evidence-based 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 AJN ▼ January 2011 ▼ Vol. 111, No. 1 55 56 AJN ▼ January 2011 ▼ Vol. 111, No. 1 ajnonline.com •H  one PICOT question and assure team is prepared • Build EBP knowledge and skills • Begin relationship with EBP Mentor • • • • •C  ritically appraise literature • Meet with group to discuss how completely evidence answers question; pose follow-up questions and re­­ review the literature as necessary • Begin relationship with EBP Mentor •M  eet with group • Summarize evidence with focus on implications for practice and conduct interviews with content experts as ­necessary to benchmark • Begin formulating detailed plan for implementation of evidence • Include who must know about the project, when they will know, how they will know • Begin relationship with EBP Mentor •D  efine project purpose—connect the evidence and the project • Define baseline data collection source(s) (for example, existing datasets, electronic health record), methods, and measures • Define postproject outcome indicators of a successful project • Gather outcome measures • Write data collection protocol • Write the project protocol (data collection fits in this document) • Finalize any necessary approvals for project implementation and dissemination (for example, system leadership, unit leadership, IRB) • Begin relationship with EBP Mentor Checkpoint One Checkpoint Two Checkpoint Three Checkpoint Four Checkpoint Five  onduct literature search and retain studies that meet criteria for inclusion C Connect with librarian Meet with implementation group – TEAM BUILD Begin relationship with EBP Mentor • Who are the stakeholders for your project  Active (on the implementation team) and Supportive (not on the team, but essential to success) • Identify project team roles and leadership • Begin acquisition of any necessary approvals for project implementation and dissemination (for example, system and unit leadership, internal review board [IRB]) • Begin relationship with EBP Mentor ARCC EBP Implementation Plan Preliminary Checkpoint EBP Mentor and Contact Info: Team Members: PICOT Question: Figure 1. EBP Implementation Plan Template Notes: Notes: Notes: Notes: Notes: Notes: ajn@wolterskluwer.com AJN ▼ January 2011 ▼ Vol. 111, No. 1 57 •M  idproject meet with all key stakeholders to review progress and provide outcomes to date • Review issues, successes, aha’s, and triumphs of project to date • Begin relationship with EBP Mentor •C  omplete final data collection for project evaluation • Present project results via poster presentation—locally and nationally • Celebrate with EBP Mentor and Agency Leadership •R  eview project progress, lessons learned, new questions generated from process • Consult with EBP Mentor about new questions Checkpoint Nine Checkpoint Ten Checkpoint Eleven Notes: Notes: Notes: Notes: Notes: Notes:  Fineout-Overholt, 2009. This form may be used for educational purposes without permission. If you use it for your practice change, please let us know by e-mailing © ellen@transforminghealthcarewitharcc.com. •P  oster presentation (preferred event is a system-wide recognition of quality, research, or innovation)

• LAUNCH EBP implementation project • Begin relationship with EBP Mentor Checkpoint Eight  eet with implementation group to review proposed poster M Make final adjustment to poster with support staff Inform stakeholders of start date of implementation and poster presentation Address any concerns or questions of stakeholders (active and supportive) Begin relationship with EBP Mentor  eet with implementation group M Discuss known barriers and facilitators of project Discuss strategies for minimizing barriers and maximizing facilitators Finalize protocol for implementation of evidence Identify resources (human, fiscal, and other) necessary to complete project Supply EBP Mentor with written IRB approval and managerial support Begin work on poster for dissemination of initiation of project and progress to date to educate stakeholders about project—get help from support staff Include specific plan for how evaluation will take place: who, what, when, where, and how, and communication mechanisms to stakeholders Begin relationship with EBP Mentor • • • • • • • • • • • • • • Checkpoint Seven Checkpoint ­Six (about ­midway) 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 prov­als of these RRT projects lends confidence to their intervention. Rebecca and Chen know it’s important 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 pinpointing those aspects of their T able 1. Potential Sources and Types of Internal Evidence 58 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 diagnosis­related 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 ­Med­­ical Records/ Information Technology Patient history Patient assessment Diagnostic test results Medication regime Plan of care Data collected, submitted to and benchmarked with outside sources National Database of Nursing Quality Indicators Centers for Medicare and Medicaid Services Patient satisfaction survey ­organizations AJN ▼ January 2011 ▼ Vol. 111, No. 1 study or project that may increase risk of any kind to the people involved.

The team seeks out more information on their hospital’s Web site and finds the appropriate form for an implementation project. They agree to complete the form together as they develop their implementation plan. Checkpoint five and for­ward. As the team moves on to Checkpoint Five in the EBP Implementation Plan template, Carlos talks to them about the critical importance of defining the purpose of the project. Purpose of the project. A clearly defined purpose sets the entire plan­ning process in motion, Carlos 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. Carlos 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 explains that various data are generated within the hospital, which he calls internal evidence. The sources for these data are in various locations and are referred to in a variety of ways, such as: qual­ ity management, risk management, finance, and human resources departments; clinical systems; operational 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 Credentialing Center’s Magnet Recognition Program, can also be used as outcomes. As an example, he pro­ vides reports from their hospital’s quality commit­tee that include data for CRO, UICUA, and overall hospital mor­tality. 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 quality 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 requesting those data. EBP and the Theory-Practice Gap

Carlos helps the team understand that obtaining data may be complicated at times, but one’s success greatly de­pends on knowing whom to ask. To help the team capture the out­comes data they’ll need to obtain at baseline and again after the project, Carlos recommends they work with the information technology 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 busi­ness 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 process of implementing an RRT in their hospital goes well. Rebecca reminds the team about their and the MERIT trial authors’ observations on how the MERIT trial was conducted, particularly on how the RRT protocol was imple­ mented.5 EBP and the Theory-Practice Gap

(The control hospitals’ code teams may have functioned as RRTs, which could ­explain why there was no difference between 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 ajnonline.com 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 priorities of the organization (business plan, accreditation, reimbursement, licensing) Hospital strategic plan; CRO, UICUA, and NIM data; and expected targets …EBP and the Theory-Practice Gap