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WHAT, WHERE, WHEN, HOW, & WHY
©Kaiser Permanente
RESEARCH OR PI?
Cecelia L. Crawford RN, DNP; SCAL Regional Nursing Research ProgramLynn M. Garofalo DPPDc, MHA; SCAL Healthcare PI Mentor
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LEARNING OBJECTIVES•At the end of this presentation, the learner will be able to:–State 3 differences between nursing research and performance improvement
–Describe 2 methods to achieve the unique objectives of Research and PI
©Kaiser Permanente
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THE CONCEPT OF RESEARCH
• Research is not isolated activities or tasks• Surveys, interviews, and observations• Data collection• Statistical analysis• Improvement processes• Evidence-based practice changes
©Kaiser Permanente
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THE CONCEPT OF RESEARCH
•Research is a rigorous, reproducible, and systematic process that may involve all or part of those tasks and activities
©Kaiser Permanente
RESEARCH
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A rigorous & systematic process• Generates new knowledge through the
application of basic scientific principles and theory development
• Overarching intent of research is description, prediction, and control
• Asks “What is not known?”• Final product = new knowledge that can be
generalized in appropriate patient populations©Kaiser Permanente
FACTORS NECESSARY FOR RESEARCH SUCCESS
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• Successful research studies always have these two elements:– A committed research team (not one or two people)
with a passion for the clinical problem• Teams members with various talents, expertise,
and research experience
– An expert researcher to ensure a systematic and research-based approach, who is either:• Part of the research team OR• A consult for the research team
©Kaiser Permanente
THE PROCESS OF KNOWLEDGE DEVELOPMENT
(OMERY, 1998)
©Kaiser Permanente - Do Not Distribute 7
Data Facts Information
Analysis Synthesis
Systematic Process
(Organized Data) (Structured & Integrated Facts that are meaningful)
The research process IS the systematic process
that produces scientific knowledge
ScientificKnowledge
EVIDENCE-BASED PRACTICE
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A systematic process• Implements and evaluates interventions
stemming from new knowledge generated by research
• Overarching intent of EBP changes is to integrate scientific discoveries into healthcare practice
• Asks “What is known?” and “What can be done with this knowledge?”
• Final product = systems change and outcome improvement in patient populations
©Kaiser Permanente
PERFORMANCE IMPROVEMENT
A structured process that:• Strives to improve system specific
processes and outcomes
• Asks “what is happening and how can it be improved?”
• May contribute new learning & practices
9©Kaiser Permanente
THE PI PROCESS
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A structured evaluation process with an iterative flow
(SMART Goal) What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
AssessDevelop / Identify Change
Test Implement / Control
Understand the process and decompose the problemO
bjec
tives Generate ideas
for solving the problems
Document the new process
Run PDSA cycles to test ideas
Keep testing ideas until goal is achieved
Implement changes fully into the system
Monitor to sustain; spread if appropriate
Model for Improvement developed by Associates for Process Improvement
Act Plan
Study Do
©Kaiser Permanente
FACTORS NECESSARY FOR PI SUCCESS
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• Successful performance improvement projects always have:– A committed improvement team (not one or two
people) with a passion for the problem
–They may also have a PI expert to ensure a structured approach, who is either:• Part of the improvement team OR• A consultant for the improvement team
©Kaiser Permanente
RESEARCH & PI• Similarities
• Start with data and analysis
• Have a defined process• Require a committed
team for success• Contributes to
knowledge & outcome improvement
• Differences: • Structures• Processes• Intent• Outcomes• Data required
©Kaiser Permanente
STRUCTURE, PROCESS, INTENT, AND OUTCOMES
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DATA REQUIREMENTS
©Kaiser Permanente
CASE STUDY: HOSPITAL ACQUIRED PRESSURE ULCERS
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Research
Evidence-Based Practices
Performance Improvement
• Intent: Learn via retrospective chart review• Outcome: New scientific knowledge to be
generalized for adult ICU patients
• Intent: Integrate new scientific knowledge into practice
• Outcome: Fewer HAPUs
• Intent: Identify changes to achieve goal• Outcome: Reduce HAPUs on a PCU
©Kaiser Permanente
RESEARCH EXAMPLE
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A systematic process• What is not known:
Unavoidable Pressure Ulcers: A Causal Model (Primary Investigator: Anna K. Omery, 2010; Gretchen Summer, NCAL Primary Investigator)• Retrospective chart review• Adult ICU patients• Statistical analysis of
variables
• Descriptive, predictive, & controlled
©Kaiser Permanente
RESEARCH EXAMPLE
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A systematic process• Scientific knowledge via a rigorous and
systematic research process• Data• Facts• Synthesized Information• Knowledge
• Final product = New knowledge that can be generalized for adult ICU patients in the United States at risk of development HAPU
©Kaiser Permanente
EBP EXAMPLE
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Pre-albumin Screening to Decrease Hospital Acquired Pressure Ulcers
• KP Los Angeles Medical Center• What is known: Monitoring prealbumin levels
can be used as a screening tool to identify patients at risk for HAPU and plan nutritional interventions
©Kaiser Permanente
EBP EXAMPLE
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Pre-albumin Screening to Decrease Hospital Acquired Pressure Ulcers
• Systematic integration of the new knowledge into nursing practice
• Maximize patient’s nutritional regime
• Final product• Decreased HAPU• Improved QOL, decreased
pain, decreased cost, & decreased length of stay
©Kaiser Permanente
PI EXAMPLE
1. Analyzed baseline data = 12 in 4 months
2. Set SMART goal: PCU will reduce the number of HAPUs from average of 2 / month to no more than 1 / month by Sept 30, 2010
3. Assessed current practices and identified potential changes
• Better skin assessment skills needed – use 2 nurses• Create a tool to better assess patients at risk for HAPUs• Use Wound Ostomy Continence Nurse (WOCN) as resource• Investigated other practices/ interventions
20©Kaiser Permanente
PI EXAMPLE (CONTINUED)
©Kaiser Permanente - Do Not Distribute 21
Learning about patients
actively dying
Project Start
DISCUSSION• How have you used research, evidence-
based practices, and performance improvement to improve nursing care?
• What challenges have you faced differentiating when to use research vs. performance improvement?
22©Kaiser Permanente
SUMMARY• Research and PI vary in structure,
intent, processes, outcome and data requirements
• Both have similarities:• Start with data• Conduct an analysis• Need a committed team• Rely on experts for guidance
23©Kaiser Permanente
KP IRB RESOURCES
• Standard Operating Procedures• Applications, Forms, Reports• IRB Guidance• Link: http://scalresearch.kp.org/irb/index.html
©Kaiser Permanente 24
• [email protected] • http://nursingpathways.kp.org/ncal/research/nursing
researchprogram/index.html
• [email protected]• http://nursingpathways.kp.org/ncal/research/nursing
researchprogram/index.html
RESEARCH RESOURCES
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Mentors Background/Training Expertise Clients / Lead IAs / Contact
Heidi Spence
Heidi is a certified as a Master Black Belt and Lean Six Sigma Black Belt. She has15 years experience improving health care service delivery and quality. She earned a B.S. in Cognitive Psychology and a MSW
Developing improvement capability, change management and breakthrough performance improvement with front line teams. Heidi coordinates and develops Region‐wide PI training –including Physician training, managing training requests, working with Regional wave students, etc
Northwest & Hawaii Regions, Southern California Regional [email protected] :: 503.308.3848
Lynn Garofalo
Lynn has 20 years experience inhealth care improvement, and holds an BS in Finance, MHA from USC and Lean Six Sigma Black Belt Lynn’s completing Doctor of Policy, Planning and Development from USC
Health care strategy & processimprovement, organizational change management, training, and qualitative comparative analysis
Antelope Valley: Lead IA: Jeanne RhynsburgerPanorama City: Lead IA: Sarita CohenSan Diego: Lead IA: Rudy MarillaWest Los Angeles: Lead IA: Lisa SaldanaNational Pharmacy [email protected] :: 310.848.4737
Maria Lee
Maria has 15 years in Performance Improvement, a PhD from MIT, an MBA from UCLA & a Master Black Belt from Motorola
Patient flow, finance/revenue cycle,lean operations, clinical & non‐clinical operations, Six Sigma, DMAIC & DFSS
Downey: Lead IA: Rhonda AlfaroLos Angeles: Lead IA: Yannis AngourasOrange County: PI Dir: Judy [email protected] :: 818.588.0687
Michael Falk
Mike has 15 years experience as a Lean Six Sigma Master Black Belt and is an ASQ Certified Reliability Engineer (CRE) with a BS in Business and a MS in Quality Assurance
Innovative process designs(scorecard and dashboard development), Quality Systems and Supply Chain improvement portfolios
Kern County: Lead IA: Victoria GraftonSouth Bay: Lead IA: Sharon WrightWoodland Hills: Lead IA: Debbie [email protected] :: 805.814.2464
Michael Mertens
Mike is certified in Lean Six Sigma MasterBlack Belt, Black Belt and Design for Six Sigma. He has15 years experience doing improvement work in large global companies. He has a BSE in Mechanical Engineering
He has led projects in many different areas applying Lean, Six Sigma and Design for Six Sigma methodologies
Baldwin Park: Lead IA: Dawn (Cheryl) FairbairnFontana/Ontario: Lead IA: Ahmad MohammadRiv/Moreno Valley: Lead IA: John DorothySCAL Member Services [email protected] :: 714.681.0255
SCAL PI MENTORS
CECELIA’S RABBIT HOLE
Cecelia L. Crawford, RN, DNPTranslational Research
SCAL Regional Nursing Research Program
REFERENCES
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• Albert, N. M., & Siedlecki, S. L. (2008). Developing and implementing a nursing research team in a clinical setting.
• Feinstein Institute (2009). Quality management/quality improvement (qm/qi) activities vs. research activities subject to irb review. Available at http://www.feinsteininstitute.org/Feinstein/IRB+Guidance
• Institute of Medicine (IOM) (2001). Crossing the quality chasm: A new health system for the 21st century. Committee on Quality of Health Care in America Washington, D.C.: National Academies Press.
• Omery, A. K. (1998). The process of knowledge development. Kaiser Permanente Nursing Research Series. Available at http://nursingpathways.kp.org/scal/research/resources/researchseries/index.html#supplementary
• Polit, D. & Beck, C. (2008). Nursing Research: Generating and Assessing Evidence for Nursing Practice, 8th Edition. Philadelphia: Lippincott Williams & Wilkins.
©Kaiser Permanente
REFERENCES
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• Titler, M., Kleiber, C., Rakel., B., et al. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13(4), 497-509.
• Titler, M. (2007). Translating research into practice. American Journal of Nursing, 107(6) Supplement, 26-33.
• Wilson, C. & Sylvanus, T. (2005). Generating enthusiasm for nursing research. Journal of Nursing Administration, 35(5), 220-222.
©Kaiser Permanente
REFERENCES
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• Associates in Process Improvement. (1997) The Improvement Handbook. Austin, TX.
• Brassard, M & Ritter, D (2010), The Memory Jogger. 2nd Edition. Canada.
• Langley TW, Nolan K, Nolan T, Norman C, Provost L. (1996) The improvement guide: a practical guide to enhancing organizational performance. San Francisco, CA.
• Lloyd, RC. (2004) Quality Health Care: A Guide to Developing and Using Indictors. 1st ed. Boston, MA.
• Provost, L. P., & Murray, S. (2007). The data guide: Learning from data to improve health care. Austin, TX.
• Rother, M. & Shook, J. (2003) Learning to see: value stream mapping to add value and eliminate MUDA . Cambridge, MA.
©Kaiser Permanente