Distinguishing Between Quality Improvement, Evidence-Based Practice, and Nursing Research Maria R....

Distinguishing Between Quality Improvement, Evidence-Based Practice, and Nursing Research

Maria R. Shirey, PhD, MBA, RN, NEA-BC, ANEF, FACHE, FAANProfessor, Community Health, Outcomes & Systems

Assistant Dean, Clinical Affairs & PartnershipsUniversity of Alabama at Birmingham School of Nursing

North Dakota Center for Nursing ConferenceOctober 23, 2014 • Bismarck, North Dakota

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Introduction

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So … How Did You Get Here?

“Showcasing Differences Between Quality Improvement,

Evidence-Based Practice, and Research”

Shirey et al., (2011)

Winner of the inaugural JCEN Innovation Award for 2011

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Impact

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Presentation Objectives

• Differentiate among quality improvement (QI), evidence-based practice (EBP), and nursing research

Realistic Expectation:

Gain general understanding of concepts and their applicationReflect and brainstorm to use information more broadly

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Road Map

• Overview of the Shirey et al., (2011) article

• Application of article by others • Reflective dialogue with next steps

• Key takeaways with Q&A

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Overview of the Article

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Why Is There Need to Know?

• Recent meta-analysis identified all concepts as essential for Magnetic, healthy nursing workplace (Kramer, Schmalenberg & Maguire, 2010)

Quality & Safety of Patient Care

Research

EBPQI

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Important Definitions

Quality Improvement

Data driven systematic approach by which individuals work together to improve specific internal systems, processes, costs, productivity, and quality outcomes with an organization

Note: Terms QI and Performance Improvement (PI) used interchangeably

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Important Definitions

Evidence-Based Practice

Problem-solving approach that integrates a systematic search for and critical appraisal of the best available evidence (may or may not be research based) to answer a burning clinical, education, or administrative question

Clinician expertise and patients’ unique circumstances and preferences

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Important Definitions

Research

Scientific process that generates new knowledge and validates/refines existing knowledge that directly and indirectly influences nursing practice or health systems

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Background and Overview of the Article

• Started as discussion board assignment in DNP course

• Intent of assignment was to compare and contrast all 3 concepts of QI, EBP, Research across multiple dimensions

• No article available with extensive side-by-side comparative data, so … we created one!!!

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Building The Comparative TableSynthesis of the Literature

Main Categories QI EBP Research

Background and descriptors

Uses and Applications

Scholarship Integration

Shirey et al. (2011)

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Highlights of Comparative Table

Main Categories with Dimensions

QI EBP Research

Background and descriptors• Historical

evolution

• Commonalities and distinctions

• Key features

• Rigor

Deming; production quality monitoring

Systematic problem solving approach that is data driven

Incorporatesknowledge

Least rigorous

Cochrane; scientific evidence used to guide practice

Systematic problem solving approach that is evidence driven

Translates knowledge

Somewhat rigorous

Nightingale; scientific method of discovery in nursing

Systematic problem solving approach that is inquiry driven

Generatesknowledge

Most rigorous

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Highlights of Comparative Table

Main Categories with Dimensions

QI EBP Research

Uses and Applications• Purpose

• Use of protocols

• Data collection

• IRB approval

Improve internal processes to enhance outcomes

Yes; changing

Rapid cycle

Not usually; may be needed for pubs

Evaluate evidence and integrate into practice to enhance outcomes

Yes; systematic

Intermediate not rapid cycle

Not usually; may be needed for pubs

Develop new knowledge that is generalizable

Yes; strict

Not rapid cycle

Always; required for publication and to initiate study

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Highlights of Comparative Table

Main Categories with Dimensions

QI EBP Research

Uses and Applications• Funding

• Oversight

• Limitations

• Methodology

Usually internal

Institutional

Weak methodology;no causality

Various QI approachesi.e. PDCA

Usually internal

Institutional

Outcome only as good as “best” evidence

Various EBP modelsi.e. ARCC model (Melnyk & Fineout-Overholt)

May be internal or external

Beyond institution

Depending on analysis can establish causality

Various methodologies i.e. qualitative, quantitative or mixed methods

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Highlights of Comparative Table

Main Categories with Dimensions

QI EBP Research

Uses and Applications• Examples PDCA project to

improve door to balloon times in acute myocardial infarction patients

PDCA project to reduce 30-day hospital readmission rates in heart failure patients

Implementation of protocol for early post operative patient ambulation following release of landmark systematic review

Translation of best evidence into practice to enhance outcomes

Qualitative research to describe nurse manager work complexity

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Highlights of Comparative Table

Main Categories with Dimensions

QI EBP Research

Scholarship Integration• Theoretical

underpinnings

• Generalizability

• Expectations for dissemination

• Potential for dissemination

No

No

Within facility

May be publishable

Varies

Yes, with caveat

Within facility and beyond

May be publishable

Usually yes

Yes, with caveat

Broad dissemination to scientific community

Usually publishable

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Highlights of Comparative Table

Main Categories with Dimensions

QI EBP Research

Scholarship Integration• Examples of

venues for publication

• Examples of venues for presentations

Journal for Healthcare Quality

NAHQ conferences

Worldviews on Evidence-Based Practice

EBP conferences

Nursing Research

Nursing research society conferences

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Understanding Check

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Understanding Check

Question #1If the intent of a project is to establish a cause-and-effect relationship, the best approach to use would be a/an:A. Evidence-Based Practice Project.B. Quality Improvement Project.C. Research Project.D. Institutional Project.

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Understanding Check

Question #2Given the following choices to develop an EBP project, the best methodology to use would be:A. Six Sigma.B. Plan Do Check Act.C. The Academic Model.D. The Iowa Model.

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Understanding Check

Question #3Given the choice between various approaches, a team developing a clinical work flow process using limited resources and time would likely select:A. Nursing Research.B. Evidence-Based Practice.C. Quality Improvement.D. Clinical Inquiry.

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Understanding Check

Question #4The definitive dimension the distinguishes between quality improvement, evidence based practice, and research is:A. Historical Evolution.B. Definition.C. Rigor.D. Purpose.

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Application of the Article

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The ApplicationTool for Academia

• Guide for teaching QI, EBP, Research in academic programs

• Incorporated in teaching QSEN principles (American Association of Colleges of Nursing QSEN Institute Faculty Resources)

• Referenced in numerous professional websites

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The ApplicationTool for Clinical Nursing Excellence

• Support Nursing Standards of Practice (ANA, 2010)

At fundamental level, the registered nurse participates in QI activities and integrates EBP and research into practice

• Accelerate Hospital Magnet Journey → Guide to decipher which approach to use → Identify need for IRB approval → Create Magnet evidence

• Form foundation for additional user-friendly staff development resources for clinical practice (Ryan & Rosario, 2012)

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The ApplicationTool for Clinical Nursing Excellence

Performance Improvement/Research Differentiation Form(Ryan & Rosario , 2012)

• Identify title of project

• Answer series of questions

• Determine pattern of responses

• Identify emerging dominant study category

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Ryan & Rosario (2012)

Performance Improvement

Research Uncertain

Which phrase best describes purpose of the project?

To improve internal organizational processes, practices, costs or productivity

To generate new knowledge that can be generalized

What are you trying to accomplish with this project?

To measure an existing practice that is an approved procedure or that has been shown effective in the literature

*** To test or refine an innovative practice or instrument

Will participants be placed at any risk during project?

The project does not impose risks beyond usual care

*** The project may impose some risk to participants

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Ryan & Rosario (2012)

Performance Improvement

Research Uncertain

What does the intervention in this project involve?

The project involves applying practice standards or evaluating existing practice without group comparisons

The project involves comparisons of one or more interventions that are given to some patients and not others

How are the processes or outcomes measured?

A data collection tool that has not been tested for reliability and validity is used

An instrument that is a valid and reliable measure of the concept to be tested will be used

What do you plan to do with the findings?

Communicate findings within the hospital or department setting. Findings may be published and/or presented.

Publish and/or present findings for others within the discipline

How will your findings change practice?

May change practice in this setting immediately

May change practice slowly, often after multiple studies validate the results

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The ApplicationTool for Dissemination

Different Formats for Publication of QI, EBP, ResearchOermann, Turner & Carman (2014)

Guidelines for

Reporting

ResearchIMRAD

QISQUIRE

EBPPRISMA

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The ApplicationTool for Dissemination

Guideline Definition and Website Resource Categories

QI SQUIRE Standards for Quality Improvement ReportingExcellencehttp://squire-statement.org/

Title, Abstract, Introduction, Methods, Results, Discussion, Other Information

EBP PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyseshttp://www.prisma-statement.org/

Title, Abstract, Introduction, Methods, Results, Discussion, Funding

Research IMRAD Introduction, Methods, Results, and Discussionhttp://writingwisc.edu/Handbook/ScienceReport.html

Title, Abstract, Introduction, Methods, Results, Discussion, Limitations, Conclusions, Implications, Funding

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Application Check

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Application Check

Scenario #1: QI• The hospital examines its monthly run charts on key

quality indicators

• In reviewing these data, the hospital determines the incidence of falls in hospitalized elderly patients is trending upward

• To act on this information, what should happen next?

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Application Check

Scenario #1: QI• Formulate QI question: Why is the unit level fall rate so high?

• Apply QI methodology P Identify and analyze problem D Develop and test solutions C Check effect of pilot solution A Implement solution fully

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Application Check

Scenario # 2: EBP• There is a desire to initiate a practice change that

would prevent falls in hospitalized elders

• To initiate a practice change, what should happen first?

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Application Check

Scenario # 2: EBP• Formulate clinical question using PICOT format: P Population I Intervention C Comparison O Outcome T Timeframe

In hospitalized elders (P), how does a bed alarm (I) compared to use of sitters (C) affect fall rates (O) during a 3 month time period (T)? 38

Application Check

Scenario # 2: EBP• Specify key search terms to retrieve evidence that best

answers PICOT question and meets inclusion criteria

• Generate evidence table and determine level of evidence

• Critically appraise the evidence (look at flaws and worth)

• Make practice recommendations based on best evidence

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Application Check

Level 1- Systematic review & meta-analysis of RCT

Level 2- One or more randomized controlled trials

Level 3- Controlled trial (no randomization)

Level 4- Case control or cohort study

Level 5- Systematic review of descriptive & qualitative studies

Level 6- Single descriptive or qualitative study

Level 7- Expert opinion

Melnyk & Fineout-Overholt (2011)40

Application Check

Scenario # 3: Research• You have searched the literature to obtain information about

the incidence of falls in hospitalized elders

• You find the literature is not current and it does not incorporate cultural aspects pertinent to your unique elderly patient population

• How do you go about developing a permanent solution for elderly patient falls in your patient population?

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Application Check

Scenario # 3: Research• Identify problem statement

• Formulate research question: What factors contribute to falls in non-English speaking hospitalized elderly patients?

• Use research question to guide methodology (design, sampling, data collection, data analysis methods)

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Reflection with Next Steps

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Stretch and Energize to Focus

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Reflective Question

Now that you have heard this presentation, what ideas do you have for HOW you would

immediately begin using the information in your practice and work setting?

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Think, Pair & Share

• Turn to person next to you

• Discuss the following for 5-minutes: How would you begin to immediately use the information from this presentation in your practice and/or work setting?

What partnerships or networks might you leverage? Why?

• Take 5-minutes to share your ideas with the broader audience

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Synthesis Check

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Key Takeaway Points

• Correctly differentiating among QI, EBP, and research = → Essential for patient care quality/safety

→ Needed to advance nursing practice and science

• Understanding concept differences enhances applicability, integration, collaboration opportunities, and ultimately our IMPACT

• Proficiency comes from learning and doing

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Closing

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Questions & Answers

Maria R. Shirey, PhD, MBA, RN, NEA-BC, ANEF, FACHE, FAANProfessor, Community Health, Outcomes & Systems

Assistant Dean, Clinical Affairs & PartnershipsUniversity of Alabama at Birmingham School of Nursing

mrshirey@uab.edu

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References

American Nurses Association. (2010). Nursing scope and standards of practice. Washington, DC: ANA.

Kramer, M., Schmalenberg, C.& & Maguire, P. (2010). Nine structures and leadership practices essential for a magnetic (healthy) work environment. Nursing Administration Quarterly, 34(1), 4-17.

Melnyk, B. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.

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References

Oermann, M.H., Turner, K. & Carman, M. (2014). Preparing quality improvement, research, and evidence-based practice manuscripts. Nursing Economic$, 32(2), 57-69.

Ryan, M. & Rosario, R. (2012). Creating staff confidence in distinguishing between performance improvement and research studies: A user-friendly worksheet. Journal of Nursing Administration, 42 (7/8), 369-374.

Shirey, M. R., Hauck, S. L., Embree, J. L., Kinner, T. J., Schaar, G. L., Phillips, L. A., Ashby, S. R., Swenty, C. F., & McCool, I. A. (2011). Showcasing differences between quality improvement, evidence-based practice, and research. The Journal of Continuing Education in Nursing, 42(2), 57-70.

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