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CHANGING P
RACTICE T
HE
EASY W
AY
I NT
EG
RA
TI N
G Q
UA
LI T
Y &
TR
AN
SL
AT
I ON
AL
RE
SE
AR
CH
MO
DE
LS
Peggy Brown DNP, RN, APRN-CNS-BC, NE-BCClinical Quality CoordinatorThe Nebraska Medical Center
OBJECTIVES
1. Identify gaps between evidence and practice
2. Recognize the role of Translational Science in improving quality of care
3. Describe one strategy/technique that you could use to facilitate a practice change
HERE A G
AP, T
HERE A
GAP, E
VERYWHERE A
GAP,
GAP
CLOSE T
HE GAP
MEET YOUR NEIGHBOR
Share your experience with a GAP
3 minutes
FOLL
OW A
MAP
http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
TRANSLATIONAL SCIENCE
“Diffusion & implementation”
“Knowledge translation & integration”
DISSEMINATION OF EVIDENCE
R E S E A R C H E R U S E R
Practice guidelinesPublicationsTool kitsPresentations
IMPLEMENTATION OF EVIDENCE
U S E R P A T I E N T
COMPILATION OF IMPLEMENTATION STRATEGIES
• 6 process • 68 implementation strategies and
definitions
Powell BJ, McMillen JC, Proctor EK, Carpenter CR, Griffey RT, Bunger AC, . . . York, J. L. (2012). A compilation of strategies for implementing clinical innovations in health and mental health. Medical Care Research and Review: MCRR, 69(2), 123-157.
EXAMPLES OF STRATEGIES
Planning Education Strategies
Finance Restructure Strategies
Quality Management Strategies
Conduct needs assessment
Train-the-trainer
Alter incentives
Revise roles
Small tests of change
Involve executive board
Learning collaborative
Access new funding
Change physical structure
Audit-feedback
Visit other sites
Local opinion leaders
Create new service teams
Improvement advisor
Powell et al. (2012)
FOLL
OW A
MAP
TRANSLATIONAL RESEARCH MODEL TITLER & EVERETT (2001)
CHARACTERIS
TICS
OF THE E
VIDEN
CE-
BASED PRACTI
CE/INNOVA
TION
• Advantages• Compatibility with
values and needs• Complexity• Feasible• Cost
Titler (2008)
COMMUNICAT
ION
• Mass media
• Opinion leaders –local, respected, influential, competent, trusted to evaluate knowledge
• Change champions- local, expert clinicians, passionate, committed to improve quality, positive working relationships
• Consultation by experts
• Hallway chats, one-to-one
USERS• Stakeholders• Adoption of
practice varies• Audit and
feedback changes behavior
• Opinion leaders• Change agents
SOCIAL S
YSTE
M
• Organizational resources
• Organizational size• Organizational culture• Readiness for change• Structure supporting
EBP• Leadership support
Map:
Integrated quality improvement and translational research model
EBP:
Uninterrupted skin-to-skin contact at birth
IMPLEMENTATION EXAMPLE
Define
Measure
Analyze
Improve
Innovation
Communication
Social SystemUsers
Control
Adoption
Feedback Feedback
PROBLEM STATEMENT
In January of 2014, The Joint Commission began mandating that hospitals with > 1,100 births per year, report the percent of newborns that were fed breast milk only from the time of birth to the time of discharge.
From July 2012 to December 2012, 53% of eligible newborns at TNMC were fed breast milk exclusively.
DEFINE
Data recorded manually by Lactation Consultants for every newborn until automated in August 2013 with OneChart report
Goal: top 10th percentile of UHC
Top 10th percentile value unknown as new core measure and comparison data not yet available
MEASURESExclusive breastfeeding
# Newborns fed breast milk only since birth # Single, term newborns discharged alive
Skin-to-skin contact at birth# Newborns with immediate, uninterrupted SSC until after 1st
feed
# Term, singleton, healthy newborns
ANALYZESupplementation50% of breastfed newborns were supplemented with non-breastmilk (Jan’13)
Skin-to-skin contact (SSC) at birthLiterature review for evidence-based best practices revealed SSC to be the hospital practice most highly correlated with exclusive breastfeeding during hospitalization
20% of healthy term newborns received skin-to-skin contact at birth (mother interviews, Jan’13)
ANALYZE
Benefits of skin-to-skin contact at birth• Physiologic stability
oRespirations, temperature, glucose levels, decreased crying & stress
• Promotes attachment behaviorsoShort-term and long-term
• Increased exclusive breastfeeding in hospital• Longer duration of breastfeeding
Critical X’s Solution
Supplementation with non-human milk
Follow provider orders not to supplement breastfed newborns without first notifying provider. Documentation of informed decision or medical indication for supplementation with non-human milk. Education to providers, nurses and parents on indications for supplementation.
Limited skin-to-skin contact at birth
Implement evidence-based practice of Skin-to-skin contact at birth
IMPROVE – CHARACTERISTICS OF INNOVATION
Skin-to-skin contact at birth has been recommended by leading health organizations since 1998 (WHO, AAP, ABM, NRP)
Relatively simple
Requires change in work flow
Numerous benefits
IMPROVE - COMMUNICATION
Increase understanding of advantages of innovation
You-tube videos of SSCEmails
Links to websites Research abstracts
Unit meetingsClass for professionalsOne-to-one discussions with change champions/opinion leaders
Bulletin boards
Nurses & Providers
Opinion leaders
Change champions
IMPROVE - USERS
IMPROVE – SOCIAL SYSTEM
Provided structure for innovation:Shared governance structureQuality triad Policy/procedure
CONTROL – JULY 2013
Audit-feedback
Skin-to-skin contact weekly, individual
Monthly exclusive breastfeeding %
Q1'13 Q2 Q3 Q40
10
20
30
40
50
60
70
80
90
100EBF & SSC Trends
SSC EBF all healthy newborns EBF mother planned to EBF
Pe
rce
nt
Project KickoffClarification of or-ders
SSC audit feedback
SSC communica-tion began
CONTROL – JANUARY 2014
Monthly/Quarterly skin-to-skin percentages
Feedback for individual trends
10th percentile – Are we there?
SHARE WITH YOUR NEIGHBOR
Strategy you may use to enhance implementation of the next evidence-based practice
3 minutes
OBJECTIVES
1. Identify gaps between evidence and practice
2. Recognize the role of Translational Science in improving quality of care
3. Describe one strategy/technique that you could use to facilitate a practice change
Powell BJ, McMillen, JC, Proctor EK, Carpenter CR, Griffey RT, Bunger AC, . . . York, J. L. (2012). A compilation of strategies for implementing clinical innovations in health and mental health. Medical Care Research and Review: MCRR, 69(2), 123-157.
Rogers, E.M. (2003). Diffusion of Innovations. New York : Free Press.
Titler MG, & Everett, L. Q. (2001). Translating research into practice. considerations for critical care investigators. Critical Care Nursing Clinics of North America, 13(4), 587-604.
Titler, M. G. (2010). Translation science and context. Research & Theory for Nursing Practice, 24(1), 35-55. doi:10.1891/1541-6577.24.1.35
Titler, M. (2008). Evidence for EBP implementation. AHRQ nursing handbook (1st ed., pp. Ch 7)
Titler, M. G. (2011). Nursing science and evidence-based practice. Western Journal of Nursing Research, 33(3), 291-295. doi:10.1177/0193945910388984
