Evidence-based Practice, Research, and Quality Improvement What s the Difference? Susan B Stillwell, DNP, RN, CNE, ANEF, FAAN Associate Professor School of Nursing University of Portland Portland, OR Quality Health Care 1
11/28/2012 IOM Definition of Quality degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Institute of Medicine, (2001). Crossing the Quality Chasm, Washington: D. C.: National Academy Press 2
AHRQ Quality health care means doing the right thing, at the right time, in the right way, for the right person and having the best possible results. http://archive.ahrq.gov/consumer/qnt/qntqlook.htm Quality Care Monitor Quality of Care Measures Benchmarks 3
Quality Indicators ANA NDNQI program AHRQ quality, safety, efficiency, and effectiveness of health care IOM safe, effective, patient-centered, timely, efficient, equitable Year 2020, 90 percent of clinical decisions will reflect the best available evidence Quality Healthcare Approaches Evidence-based Practice Research (External Evidence) Quality Improvement (Internal Evidence) 4
Objectives Differentiate among Research, Quality Improvement and Evidence-based Practice Examine the Research, Quality Improvement and Evidence-based Practice processes for clinical practice Evidence-based Practice a problem solving approach evidence clinician s expertise patient preferences and values to make decisions about client care. (Melnyk & Fineout-Overholt, 2005; Sackett et al 1996) 5
EBP Formulate a Clinical Question (PICOT) PICOT Drives the Search for Evidence Appraise, Evaluate & Synthesize Evidence No Evidence A Gap? Generate Evidence Internal: OM, QI External: Research 6
Appraise, Evaluate and Synthesize Evidence valid and reliable evidence = quality (Melnyk & Fineout-Overholt, 2011) quality+ LOE = strength of evidence confidence to act (1Melnyk & Fineout-Overholt, 201) Apply Valid, Reliable and Relevant Evidence Evaluate Outcomes EBP 7
EBP provides clinicians the tools to translate the evidence into clinical practice and integrate it with internal evidence to improve the quality of healthcare and patient outcomes (Melnyk & Fineout-Overholt, 2011, p 5) Research A systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge DDHS, 2005, Code of Federal Regulations: Protection of Human Subjects, http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm#46.102 8
Research Process (Burns & Groves, 2009) Formulate a research problem and purpose Review relevant literature Develop a framework Formulate research objectives, questions or hypotheses Define research variables Make assumptions explicit Identify limitations Research Process (con t) Select a research design Define the population and sample Select methods of measurement Develop a plan for data collection and analysis IRB Implement the research plan Pilot, collect data, analyze data, interpret research outcomes Communicate research findings 9
Research Knowledge seeking Knowledge is generated not implemented Uncertainty that an intervention is beneficial aim is to produce knowledge that is generalizable No immediate improved care Baily et al (2006) p. s11 EBP Research 10
EBP and Research No evidence Gap in Knowledge Research Research and EBP External evidence Valid, reliable, applicable Practice Change 11
Quality Improvement Systematic, data-guided activities designed to bring about immediate improvement in heath care delivery in particular settings (Lynn et al. 2007) Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems (Hughes, 2003) Quality Improvement Directed toward the organization's processes (practices) and generating solutions specific to the local setting (Reinhardt & Ray, 2003) 12
Quality Improvement There is no one method to define QI (Varkey, Reller & Resar, 2007) PDSA cycle, Six-Sigma Lean methodology PDSA Aim Plan Do Study Act Langley et al (2009) 13
EBP and QI No evidence Local setting QI QI and EBP Internal evidence Integrated with external evidence EBP 14
What if? A QI initiative involves testing an intervention, using patients as subjects, comparing groups or subjecting patients to additional risks or burdens beyond usual practice? Baily, Bottress, Lynn & Jennings (2006) Then Think QI Research http://answers.hhs.gov/ohrp/questions/7285 What?Implement an untested clinical intervention not onlyimproving the quality of care but also collecting data about patient outcomes Intent: to establish scientific evidence Why? to determine how well the intervention achieves its intended results 15
Research vs. QI vs. EBP Research: Research is a diligent, systematic inquiry or investigation to validate, and refine existing knowledge and generate new knowledge (Burns & Groves, 2009, p 2) QI: Use of data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems (QSEN) EBP: A problem solving approach Evidence Clinician s expertise Patient values and preferences To make decisions about patient care (Melnyk & Fineout-Overholt, 2005; Sackett et al 2000) Research vs. QI vs. EBP Research: Purpose: Generate new knowledge and add to the existing evidence. Context: Often professional interest QI: Purpose: Improve local systems. Context: Local practice EBP: Purpose: Search for and appraise evidence to answer a clinical question. Context: Practice problem 16
Research vs. QI vs. EBP Research: QUESTION: Research questions are usually directional Does the use of sitters decrease falls in hospitalized elders? QI: QUESTION: QI questions are about fixing problems (aim) Why is our fall rate so high? (Decrease the percentage of falls from 15% to 0%) EBP: QUESTION: EBP questions are not directional In hospitalized elders(p), how does a bed alarm(i) compared to use of sitters (C) affect fall rates (O) in 4 months (T)? Research vs. QI vs. EBP Research: QUESTION: Research questions are usually directional Does the use of a foleyinsertion checklist decrease CAUTI QI: QUESTION: QI questions are about fixing problems Why is our CAUTI rate so high? (Decrease the percentage of CAUTI to 0%) EBP: QUESTION: EBP questions are not directional In hospitalized patients needing urinary catheterization (P), how does a checklist(i) compared to no checklist (C) affect infection rates (O) in 4 months (T)? 17
Research vs. QI vs. EBP Research: Literature Review Summarizes background and significance of the problem, documenting the current knowledge of the problem; provides justification for further study; guides methodology; not for the purpose of clinical decisionmaking QI: MODELS Example: PDSA Test of Change Ideas, one selected and tested EBP: Search the literature for the best evidence Exhaustive search for all research conducted on the topic as well as other evidence to answer the question; systematic search of the literature Research vs. QI vs. EBP Research: Critique Literature Comprehension Comparison Analysis Evaluation Conceptual clustering Synthesizing (Burns & Grove, 2009) QI: MODELS Example: PDSA Test of Change Ideas, one selected and tested EBP: Appraise evidence Evaluate and Synthesize How valid How reliable How applicable 18
Research vs. QI vs. EBP Research: QI: EBP: Carry out the study Analyze results Disseminate PDSA (test change) DO Study Act Implement evidence Evaluate Outcome(s) Disseminate Research EBP QI EBP QI Research 19
EBP Research QI Highly Recommended Shirey, M. R. et al. (2011) Showcasing differences between quality improvement, evidence-based practice and research. Journal of Continuing Education in Nursing 42(2) 57-68 20
References Baily M., Bottrell, M., Lynn, J., Jennings, B. (2006). The ethics of using QI methods to improve health care quality and safety. Hastings Center Report July-August S1-S39. Burns, N. & Grove, S. (2009) The practice of nursing research. St Louis: Saunders Elsevier. Hughes, R. Tools and strategies for quality improvement and patient safety. In Hughes RG (ed) Patient Safety and Quality: An evidencebased handbook for nurses (Prepared with support from the Robert Wood Johnson Foundation.). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; April 2008 Reinhardt, A., & Ray, L. (2003). Differentiating quality improvement from research. Applied Nursing Research 16(1) 2-8. 21
Institute of Medicine (2001). Crossing the quality chasm. IOM Washington DC: National Academy Press. Langley G.L. Nolan K.M. Nolan T.W. Norman C.L. Provost L.P (2009) The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd Edition). Jossey Bass, San Francisco Lynn et al (2007). The ethics of using quality improvement methods in health care. Annals of Internal Medicine 146, 666-673. Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-based Practice in Nursing & Healthcare: A guide to best practice. Philadelphia: Lippincott 22
Sackett D. l., Rosenberg, W.M., Gray, J.A., Haynes, R.B., & Richardson, W.S. (1996). Evidence-based medicine: What it is and what it isn t. British Medical Journal, 312(7023), 71-72. Varkey, P., Reller, K., & Resar, R. (2007). Basics of quality improvement in health care. Mayo Clinic Proceedings 82(6), 735-739. 23