Nurses Doing Mighty Things! Using Research, EBP and Analytics to Create Needed Change Sheila Cox Sullivan, PhD RN ONS Director, Research EBP & Analytics Office of Nursing Services Washington DC
Objectives At the end of the session, the learner will be able to: Discuss the responsibilities of nurses at all levels in research, EBP and/or analytics. Distinguish between Research, EBP, Quality Improvement, and System Redesign Describe how to recognize EBP in point-of-care practice Identify two uses of analytics to guide nursing practice
To Care for Those Who Shall Have Borne the Battle, and for Their Widow, and Their Orphan - Abraham Lincoln
Department of Veterans Affairs Department of Veterans Affairs Veterans Business Administration Veterans Health Administration National Cemetery Administration
VA Healthcare System Largest US healthcare system Constantly changing Currently undergoing major transformation Depend on staff for innovation and creativity to provide best evidence based practice to Veterans
Department of Veterans Affairs Under Secretary Veterans Health Administration 18 Veteran Integrated Service Networks (VISN) Central Office Program Offices
VHA Mission Statement Honor America s Veterans by providing exceptional health care that improves their health and well-being
VA Healthcare Administration Facilities & Organizations 168 Medical Centers 135 Community Living Centers 278 Vet Centers 48 Domiciliary / Residential Rehabilitation Treatment Programs 800 + Community Based Outpatient Centers Veterans 8.8 Million Enrolled 4.67 Million Receiving Care 8
VHA Workforce Nursing Personnel 96,000 73% Dentist 1235 1% Physicians 26,303 20% Pharmacists 8,489 6% VA: 379,764 employees VHA: 337,340 employees
VA Nursing Workforce: FY 2017 Registered Nurses: 68,627 Nurse Practitioner: 5,544 Clinical RN Specialist: 474 Certified RN Anesthetists: 1,024 LPNS/LVNS: 15,053 Nursing Assistants: 12,648 Total Nursing Personnel ~96,000
Office of Nursing Services (ONS) CNO Linda McConnell, MSN, RN, NEA-BC, FACHE DCNO Alan Bernstein, MS, RN Workforce and Leadership Kathleen J. Barry RN, MHA, NEA-BC Policy, Education, and Legislation Karen Ott, DNP, RN Clinical Practice Christine Engstrom, PhD, CRNP, AOCN, FAANP Research, EBP, & Analytics Sheila Cox Sullivan, PhD RN 11
Common Methodologies for Change Research Quality Assurance/ Improvement Evidence Based Practice Systems Redesign Intent Generate knowledge Ensure or improve optimal patient care Apply the best evidence from research into practice Enable robust implementation of process changes Purpose Systematic testing of theory or hypotheses that investigates areas with limited or no knowledge Systematic datadriven improvements in particular settings Problem-solving approach to clinical decisionmaking that integrates best available evidence into practice Application of findings from the implementation science literature that incorporates staff engagement and ownership in the improvement ONS EBP Goal Group, 2012
Research A systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge. Activities which meet this definition constitute research for purposes of this policy, whether or not they are conducted or supported under a program which is considered research for other purposes. For example, some demonstration and service programs may include research activities. http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr4 6.egulations (45 CFR 46.102)
VHA Blueprint for Excellence Strategy 7: Lead the nation in research and treatment of military service-related conditions Advance Knowledge on Improving Individual and Population Health Improve Electronic Communications with Veterans Use Engineering and Technology to Improve the Lives of Veterans with Disabilities Advance Innovations in Women Veterans Health Care Rapidly Translate Research Findings and Evidence-Based Treatments into Clinical Practice Conduct Veteran-Focused Comparative Effectiveness Research Enhance VA Care with Research on Complementary and Alternative Medicine 15
Groundbreaking Research 3 Nobel Prize recipients in Medicine or Physiology; 7 Lasker Award recipients. Implantable cardiac pacemaker, the first successful liver transplants, & the nicotine patch to help smokers quit smoking. Nurses developed bar-code software for administering medications. CLICK TO EDIT MASTER Dr. Jane Anderson s and Dr. Stephanie Daniels nurse-administered swallow screening for stroke patients. INTRO TITLE With Defense Advanced Research Project Agency (DARPA), brainstimulated artificial limbs & demonstrated totally paralyze patients can control robotic arms using thoughts Braingate, featured on 60 Minutes. Click to edit Master Intro Sub Title Dr. Lauren Broyles Interdisciplinary Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) conducted by nurses would be comfortably received by hospitalized Veterans. Genetic risk factors for schizophrenia, Alzheimer s, and Werner s syndrome Click to edit Submitted to U.S. Department of Veterans Affairs Dr. Christine Kasper s geno-toxic effects of embedded heavy metals in war-related retained shrapnel. By Click to edit Author Telehealth and personal-assistance technology: Dr. Bonnie Wakefield s e-health technologies for chronically ill patients; web-based mobile apps to improve point-of-care quality and safety. Electronic health records U.S. Department of Veterans Affairs
U.S. Department of Veterans Affairs Excellence Today Dr. William A. Bauman and Dr. Ann M. Spungen, National Center of Excellence for the Medical Consequences of Spinal Cord Injury, VA Medical Center, Bronx: Service to America Medal recipients. Drs. Susan Thomason and Audrey Nelson: developed pressure ulcer measure tool (PUMT) to assess wound healing. Dr. Gail Powell-Cope studying PUMT implementation to monitor wound healing in patients with spinal cord injuries/disorders. CLICK TO EDIT MASTER INTRO TITLE Dr. Beth Taylor: Paralyzed Veterans of America Clinical Advocacy Award Nursing recipient for leadership in Spinal Cord Injury Click to Patient edit Unit Master staffing Intro models. Sub Title Dr. Michael Oxman, VA San Diego Healthcare System: John B. Barnwell Award recipient for leadership in VA s Shingles Prevention Cooperative Study (CSR&D s highest award for scientific achievement). Million Veteran Program: Click to edit Submitted to U.S. Department of Veterans Affairs Dr. Pat Quigley: fall and fall injury prevention projects, tool kits and multi-site collaboratives influencing fall prevention agenda and products across the discipline. By Click to edit Author Dr. Eileen Collins: Thomas L. Petty Distinguished Pulmonary Scholar Award for significant advances in the field of pulmonary rehabilitation
Million Veteran Project
CLICK TO EDIT MASTER INTRO TITLE Jill Bormann, Ph.D., RN, FAAN received two prestigious nursing awards for her extensive body of research on the use of a Mantram Repetition Program (MRP), a complementary, mind-bodyspiritual intervention for symptom management and well-being. Click to edit Master Intro Sub Title U.S. Department of Veterans Affairs Click to edit Submitted to U.S. Department of Veterans Affairs By Click to edit Author The two awards are: 2017 International Society of Psychiatric-Mental Health American Academy of Nursing Raise the Voice, Edge Runner Award
YOUR Role in Research It takes an average of 17 years before 14% of research findings lead to widespread changes in care. Don t believe it?
ONS Definition of EBP Evidence based practice is the integration of best available evidence, clinical expertise and patient preferences at the point of practice. 22
EBP Evolution 1992 Guyatt EBP Workgroup 1996 Sackett, et al 1996 Mulhall 2005 Straus, et al 2008 Sigma Theta Tau 2012 Dearholt & Dang A new paradigm for medical practice stressed examination of evidence from clinical research. it s about integrating individual clinical expertise and the best external evidence. Evidence-based care concerns the incorporation of evidence from research, clinical experience, and patient preferences into decisions about the health care of individual patients. requires the integration of the research evidence with our clinical expertise and our patient s unique values and circumstances. process of shared decision-making between the practitioner, patient and others significant to them based on research evidence, the patient s experiences and preferences, clinical expertise and other available robust sources of information. EBP considers internal and external influences on practice and encourages critical thinking in the judicious application of such evidence to the care of individual patient, a patient population, or a system.
Nursing Evolution Industrial Model of Nursing Efficient, cost effective, specific focus Individual is trained only for specified task assigned Training is fast, resource conservative & linear Kramer, Brewer, et al, 2014 Professional Model of Nursing Development of holistic professional practice Individual is EDUCATED & skilled in performance of the whole task as the profession defines Continual assessment & modifications to care based upon changing patient needs, preferences and response to care Complex management of care, multiple patients within multiple complex systems 24
Why EBP? Demonstrated Improvement : Quality of patient care Patient outcomes Patient satisfaction Patient safety Nurse safety Nurse Satisfaction Nursing Culture Budgetary impact Aligns With: Excellence frameworks: Baldridge, Magnet, Pathway to Excellence VHA initiatives for Excellence in Veteran Care 25
History of EBP as ONS Initiative Establish the Strategic Goal for Evidence Based Nursing Practice Create an environment of inquiry in which all nurses apply the best available evidence to improve healthcare delivery and outcomes throughout VHA Establish the Evidence Based Practice Goal Group Development of facilitylevel infrastructure for EBP Consultation visits Consultative calls Educational programs Online resources 26
Best Available Evidence Clinical Expertise Patient Preferences 27
EBP occurs within and is influenced by the context of the specific health care environment Best Available Evidence Patient Preferences Clinical Expertise
EBP PROCESS ASK AQUIRE APPRAISE APPLY ASSESS Evidence Focus Practice Recommendation Implementation of evidence-based intervention
From Project to PRACTICE
EBP Framework Enforce policy Establish an expectation of an evidentiary basis for policy formation Promote a spirit of inquiry Model an Evidence- Based Practice Nurse Exec Shared Governance Provide NE with evidence to answer policy queries Oversight of Evidence-Based policy updates Dissemination of new NE approved policies with supporting evidence Know and follow policy Know current literature relevant to practice Be willing to ask questions when policy and literature are incongruent Individual Nurse
Analytics is the discovery, interpretation, and communication of meaningful patterns in data. Analytics
I can t do that!
Types of Analytics Descriptive Predictive Prescriptive
Unit Measure Falls CAUTI # Days Since 26 Last Event 150 Actual # last 30 days 2 0 Current Rate:.25% 0% Benchmark/ Goal 0 0 Team Leader: EXAMPLE Nurses Making a Difference KD JZ ICU Performance Improvement Points What we focus on to keep you safe & comfortable! Did you understand your discharge instructions? Rate (Average rating Scale of 1-5) Number of Quick Cards Collected Benchmarks: VISN Average: 3.7 National Average 3.65 Did We Meet Your Expectations? Base line April 2017 May 2017 June 2017 3.6 3.0 3.75 12 14 15 Data Source: SHEP, monthly Quick Cards July 2017 Updated by: Nurse Manager Aug 2017 Sept 2017 Average # of 15 pts per day Working Together to Improve Your Health Hand Hygiene Baseline April 2017 Percentage 88% Actual Numbers Actions Planned 35/40 May 2017 June 2017 July 2017 Aug 2017 ICU Primary Focus: improve CHG Documentation What: Documentation of Daily CHG Bath Who: Nursing Why: Decrease infections How: Chart Audit When: Weekly Audits Benchmark/Goal: 100% 100% 95% 90% 85% % CHG Documented Data Source: Observation Target: 100% Reported by: Team Lead 80% 75% 38 70% Baseline Week 1 Week 2 Week 3 Week 4
Louisville ICCU Unit Tracking Board 39
Blay, E., DeLancey, J. O., Hewitt, D. B., Chung, J. W., & Bilimoria, K. Y. (2017). Initial public reporting of quality at Veterans Affairs vs. non- Veterans Affairs hospitals. JAMA Internal Medicine. Doi:10.1001/jamaintern med.2017.0605
What questions do you have based on this data?
By Modaniel - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=36478653
Examples of Analytics Impacting your practice Staffing methodology Health and life insurance Care needed