Lesson 11
The Relationship of Evidence Based Practice to Quality Improvement©
Marilyn Stapleton, PhD, RN
LEARNING OBJECTIVE
The learner will explain the relationship between EBP and quality improvement.
OVERVIEW
You have learned that there are many clinical problems that can be addressed by using EBP (Lesson 3). Quality improvement (QI) is another process in healthcare that uses evidence to assure that patients receive the best care while achieving optimal outcomes. QI processes focus on a health care system, or, a part of a system. It can take into consideration cost of care, client satisfaction, and optimal clinical outcomes. Many times by improving one aspect of a care system, it results in the improvement of the other areas of the system.
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QI projects are similar to EBP in that there is evidence that drives the project. Typically the project will set a goal that reflects a benchmark (set from internal or external evidence). Frequently you will find QI projects have process and outcome measures. For example, if a patient care unit has a goal to improve patient satisfaction with pain management, the RNs would collect data on the level of compliance of nurses with the expected frequency of pain assessment and the re-assessment after a pain management strategy is used (process measure related to the standard of care). Also, the RNs would evaluate the effectiveness of their practice by reviewing the results of the unit’s patient satisfaction survey and compare it to a benchmark (outcome measure). In the example above the process measure is the assessment of to what extent the RNs are compliant with the units standard for pain management, the outcome measure is patient satisfaction.
There are several sources of QI projects. Many times QI projects stem from a documented history of certain defects in the facility. For example, if medication errors are at a high rate on a particular type of unit, it may spur a QI project to correct the problem. QI projects usually involve the participation of many disciplines. Other QI projects can also be stimulated in a facility by a desire to be compliant with external regulators, e.g., JCAHO. JCAHO has published series of Patient Safety Goals that healthcare institutions must become compliant. Several of these focus on medication safety; these projects would involve the disciplines of nursing, pharmacy and medicine to implement.
EBP guidelines underpin many recommended systems changes. These guidelines have translated evidence into statements of best practice. Panels of experts come together and evaluate the strength of the evidence to determine the best course of action or best practice. The Centers for Medicare and Medicaid Services (CMS) stipulate expectations for providers of care to adhere to EBP standards derived from published research. These initiatives focus improvement of care delivery in areas such as community acquired pneumonia, CHF, surgical infection prevention and myocardial infarction. The Institute for Healthcare Improvement (http://www.ihi.org) is yet another source for established standards of care combined with proven strategies, if used that can improve clinical outcomes. For example, the recent IHI “Save 1000,000 Lives Campaign” provided a framework based on EBP guidelines for several clinical projects that assured the improvement of care outcomes and the sparing of life.
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QI projects are not considered research projects that result in the production of new knowledge by answering a research question or hypothesis. These research projects use study methods to control for factors such as bias and the validity of the measurement tools. If you wanted to answer the question “What is the optimal postoperative day to teach a newly diagnosed diabetic hip surgery patient self care?” you would design and implement a nursing research study. If you wanted to answer the question “What is the effectiveness of our new falls risk reduction program?” you would design and implement a QI project In the EBP the PICO question related to falls is “In elderly hospitalized patients, what is the effect of hourly nursing rounds on reducing falls compared with bedside call light and low bed positioning?” (see Lesson 5).
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