Evaluating Challenges as Evidence-Based Improvement Opportunities

Evaluating Opportunities for Evidence-Based Improvement
When you evaluate whether an organizational challenge presents an opportunity for evidence-based improvement, you’ll want to refamiliarize yourself with the EBP process and consider each of the steps and elements related to the identified challenge.

Evidence-Based Practice
As you recall, EBP is the process of searching for, identifying, appraising, and integrating the most relevant, timely, and best evidence to answer a PICOT question. EBP involves the integration of research evidence into a practice or process to address a health care challenge. It’s not about developing new knowledge or validating existing knowledge but rather about translating existing evidence so that it can be applied to mitigate the negative effects of organizational challenges.

EBP is not the same as a research study. EBP and quality-improvement initiatives are sometimes confused with research, but they are, indeed, very different. It’s important to remember that research is focused on generating evidence for practice. EBP, on the other hand, is focused on implementing evidence in practice, and evidence-based quality improvement is focused on evaluating how well practice is working (Melnyk & Fineout-Overholt, 2018, p. 697).

As you recall, the EBP process has six steps, listed below and illustrated in the diagram.

Step 1: Compose a suitable PICOT question.
Step 2: Search for the best evidence to answer the PICOT question.
Step 3: Conduct a rapid appraisal of research studies from a literature search.
Step 4: Integrate research evidence with organizational evidence, clinical expertise, and patient preferences and values.
Step 5: Evaluate the outcomes of the evidence-based intervention.
Step 6: Disseminate the findings and outcomes of the EBP change.

EBP REQUIRES SPECIFIC PICOT ELEMENTS AND A PICOT QUESTION
The important first step in the EBP process is identifying the PICOT elements and formulating a PICOT question relative to the identified challenge. Remember, to develop a PICOT question and start the EBP process, a current problem must be occurring in a specific organization, population, or both, in a specific setting.

It’s essential to understand what each element is and start by identifying and defining each of the elements, as follows:

(P) Population: Problem and/or population in a specific setting.
(I) Intervention: An intervention supported with research evidence that is feasible for the site to implement.
(C) Comparison: Current state and desired future state related to the health care or public health challenge.
(O) Outcomes: Measurable outcomes that will be analyzed to illustrate improvement.
(T) Time: 12 weeks.
Following are examples of PICOT questions for challenges in public health and health administration settings.

Public health: For patients aged 45 years and older in a public health immunization program (P), will providing an influenza vaccine (I), compared to not providing the vaccine (C), improve the current incidence rate of influenza (O), within 12 weeks in flu season (T)?
Health administration: For an acute care hospital’s high readmission rates (P), will the application of the CMS value-based reimbursement model (I), compared to the previous reimbursement process (C), reduce the current 18 percent readmission rate for pneumonia by 5 percent (O), within 12 weeks (T)?
EBP INTEGRATES THE BEST EVIDENCE: Q AND A
Steps 2 and 3 of the EBP process revolve around evidence found in the literature. In evaluating whether a challenge might present an opportunity for evidence-based improvement, you must evaluate the available evidence itself. Consider the following questions:

Q: Is there sufficient, high-quality evidence available in the literature to substantiate the challenge?

A: If you can find only one study, this is not sufficient, high-quality evidence.
Q: Is the body of evidence large enough and wide-ranging enough to support the challenge?

A: If you find several current and relevant studies, articles, and reports to choose from, this is a large and wide-ranging enough body of evidence.
Q: Is the range of available sources of evidence wide enough to substantiate the challenge?

A: If you find authoritative source reports and peer-reviewed journal research studies and articles to compare, contrast, and weigh the evidence, this is a wide enough range.
Q: Are the sources of evidence considered reputable, acclaimed, respected, and legitimate?

A: If the sources are not nationally recognized, peer-reviewed, government-sponsored, or reputable and acclaimed, they may not be high-quality sources.
Q: Is the evidence produced by high-quality research studies and articles?

A: If your rapid critical appraisal elements are not met, you might not have found high-quality studies and articles.
Q: Is the level of evidence high, according to the pyramid of evidence scale?

A: If you found evidence from study types that are low on the pyramid, and none that are high on the pyramid, the evidence you found might not be at an appropriate level.
Q: Does evidence support the significance, magnitude, scope, and effect of the challenge?

A: If you cannot find information or data on these aspects of the challenge, you don’t have enough evidence to substantiate the challenge.
Q: Is the evidence current (produced by studies published in the last five years)?

A: If you don’t have evidence from studies or articles published within the last five years, you cannot substantiate a challenge with them, unless they are considered seminal (see the definition of seminal articles in Week 3’s readings). There are exceptions; for example, you provide a historical view of the literature related to a topic.
CURRENT STATE, BASELINE METRIC, BENCHMARKS, INTERVENTIONS
Using the following case scenario and PICOT question as an example, you see that the following identified organizational challenge involves a problem for a population in a specific setting.

For an acute care hospital in the Midwest (population/setting), will having an infection prevention tracking system (intervention), compared with not having an infection prevention tracking system (comparison), affect the number of hospital-acquired infections (outcome) during a three-month period (time)?
First, the question implies an identified organizational challenge. That is, there is no infection prevention tracking system in use at the hospital to track (and, most likely prevent, mitigate, and reduce the risk associated with) hospital-acquired infections (HAIs) that occur in this acute care hospital. What we don’t yet know are the details of the current state, and we don’t yet know the current number of cardiac arrests at the hospital. However, your research will reveal information on the significance, scope, breadth, magnitude, and effect of this type of challenge if the situation is not improved.

What Can I Do Now? Search and Review the Literature for Evidence!
In your next course (NHS8701 Keystone: Defining the Doctoral Project), after you’ve gained approval for your practicum site and preceptor, you’ll collaborate with your preceptor and site leaders to obtain background information on current activities, policies, and procedures, as well as identify a baseline metric to show the magnitude of an identified organizational challenge.

Note: In discussions with site leaders and your preceptor, before your capstone practicum, there is no need to do any data analysis. In any case, it’s not legal or ethical to analyze data until after you’ve applied for and obtained IRB approval.

Right now, in this course, you can and should conduct a search and review of the literature. For example, in the case scenario provided above, you would search for evidence in the literature to support a benchmark for the expected number or rate of HAIs in acute care hospitals in the area. You could also search authoritative sources for the number or rate of HAIs for specific populations in this specific hospital and for surrounding hospitals. In the process of reviewing the literature, you would also focus on finding research studies and articles to substantiate the significance, magnitude, scope, and effect of HAIs on patients, hospitals, the community, and others. You would also search for information and evidence on the importance and priority level of this challenge to acute care hospitals, as well as interventions and initiatives currently being implemented to improve the situation.

If current evidence is available to describe a challenge and its significance, magnitude, scope, and effect, and if you can find benchmarks to which you can compare an organization’s performance, possible measurable outcomes for the organization, and current interventions to improve the situation, then the challenge is a good candidate for evidence-based improvement.

Reference
Melnyk, B. M., & Fineout-Overholt, E. (2019). Evidence-based practice in nursing and healthcare (4th ed.). Philadelphia, PA: Wolters Kluwer Health.

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