From the Editor’s perspective…
Article Outline
Cindy Lewis, MSN, RN
CHANGE IS INEVITABLE. We are all subject to continual, inescapable change of one form or another in both our social and organizational lives. This certainly seems to be a fact of life. Currently, I am in the midst of working with unit staff to implement several new process changes to improve our efficiency and promote patient satisfaction. As nurses, we provide a critical role in health care adjustments to ensure patient safety and support nursing practice. There is a great need therefore for nurses to be capable of managing successful change.
Two of the most important strategies for improving clinical performance are performance improvement (PI) and evidence-based practice (EBP). When implementing a care improvement project, depending on how the issue is initially framed, either a PI program or an EBP program can be used. However, basing a project in one program or the other before exploratory data collection can result in a PI plan that just does not have all the right components.1
Some problems may involve PI in examining and redesigning processes of care. Still others will require both PI and EBP strategies to produce a strong and effective plan. When the nature of the problem is not clear at the onset, a special data-collection or root-cause analysis often is needed to determine actual current practice and its effectiveness.2
When PI and EBP are distinct programs with little connectedness, PI projects may fail to tap into relevant research evidence. Similarly, EBP projects may not access available setting-specific, structure, process, and outcome data that could help focus the EBP effort. Both scenarios could result in less improvement in care and patient outcomes than could be achieved by using both strategies.
Begin by defining and clearly identifying the problem or project. Then determine and collect the raw data to support this formulation. Ask the relevant question that evidence needs to answer. Think aloud through the process of clinical judgment to allow for correction of mistaken assumptions. Identify knowledge gaps or any additional information needed for the stakeholders. Design a strategy to solve the knowledge gap. Search for evidence to support the planned change. Appraise the evidence critically. Then integrate the evidence into the planned change. Continue to teach the planned change to all stakeholders. Evaluate the results of the new process. Last, continue to improve the process and monitor results.3
What governance structure would promote an interfacing of PI and EBP methods in pursuit of the goal of successful change management? There certainly may not be a standard approach. However, shared leadership and decentralized governance with a council structure does ensure that the right stakeholders make decisions. Using a unit-level and service line staff to initiate a project ensures that unit-based projects have the needed perspective and expertise to be successful.
Several approaches to support the stakeholders are helpful:
The goal of health care quality improvement is to eliminate the gap between current and optimal clinical performance. The ultimate overall goal is to design systems of care that support providers’ efforts to practice in accordance with evidence-based standards of care. Whichever methodology is used to implement planned change, the planning group needs to determine baseline measures and an achievable target, then select and implement a number of small steps or objectives that would lead to achievement of the goal over time.
Recognize that not all PI projects can be rigorously data and research based. However, when quality indicators or adverse events signal a deficiency in care, you should seriously consider a rigorous PI/evidence-based project. The articles within this issue share best practices and evidence-based research interventions. Share with us your projects, initiatives, processes, and models for planned change. We can learn from each other’s successes. I hope to hear from you soon!1, 2, 3
References
- Excellence in evidence-based practice: organizational and unit exemplars . Crit Care Nurs Clin North Am . 2005;17(2):127–142
- . Evidence-based quality improvement, principles and perspectives . Pediatrics . 1999;103(1):203–214
- . The PARIHS framework: a framework for guiding the implementation of evidence-based practice . J Nurs Care Qual . 2004;19(4):297–304
PII: S1062-0303(06)00066-5
doi:10.1016/j.jvn.2006.06.014
© 2006 Society for Vascular Nursing, Inc. Published by Elsevier Inc All rights reserved.
