Applying Evidence-Based Practice to Improve Quality

Challenges and opportunities to making EBP a universal reality

Not many could argue against the idea that adopting evidence-based practice (EBP) improves quality; however, not everyone knows how to apply it.

The call for evidence-based quality improvement underscores the need for realigning care to make it more effective, safe and efficient. But, as we think about how to apply EBP at the point-of-care, we must consider how EBP is incorporated into the workflow with different technology tools. Both workflow and technology are critical elements to apply EBP. We must also think about having a culture that invites inquiry and new knowledge.

Why Adopting EBP is Important

Looking back to the mid-1990s, nurses realized that to affect better patient outcomes, new knowledge must be transformed into clinically-useful forms that are effectively implemented across the entire care team and measured in terms of meaningful impact on performance and health outcomes. With that, the goal of EBP was to take current knowledge and connect it to standardize care to improve care processes and, ultimately, patient outcomes. Without EBP, healthcare providers are at risk for significant variances in care. So, not only is it important to adopt EBP, it’s also necessary to have methodologies in place to apply it and make it sustainable.

From a holistic perspective, EBP can be defined as looking at the literature of the best, currently available clinical research, as well as the clinical expertise within a specialty area, and connecting it to clinical experience. In addition, EBP considers patient values (or preferences) within a situation. These three components must work together.

Ultimately, for clinicians to apply EBP, they’ll need:

• The necessary tools
• The right culture to embrace it
• The engagement skills to bring patient values into the care process

In February 2016, Elsevier conducted a national study in collaboration with the Ohio State University College of Nursing.¹ A total of 256 nurse executives across the country were surveyed about their beliefs and perceptions of EBP, along with some environmental aspects of their organization. The study also included outcomes related to HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, patient satisfaction information and data from the NDNQI, the National Database of Nursing Quality Indicators.

One of the study’s cardinal findings was that, even though all the respondents indicated that quality and safety were the highest priority within an organization, focusing on EBP was the lowest. This is an extremely telling finding, considering that in order to achieve quality and safety, EBP must be applied.

Why is there such a gap between making quality and safety the highest priority in healthcare, and the actual adoption or application of EBP within an organization?

Closing the Gap

Patients expect to receive evidence-based care at the point-of-care. The reality though, is that this is not happening. So, we need to ask ourselves why and how we make EBP a reality so that a level of safe, quality care is delivered to patients across the care continuum.

While numerous perceived barriers to adoption have been identified, the most common are:

• The enormous amount of healthcare literature available, making it impossible for medical professionals to keep current
• Inadequate access to information technology
• The lack of time and autonomy to change practice

There are, however, several ways the industry can expand its focus on EBP:

• Make EBP an interprofessional priority and lead with nurses. Nurses are the largest workforce in the U.S. healthcare system. If we start with nurses, we can make a tremendous impact. This means pushing nurses to practice at the top of their license and embrace EBP. Ultimately, this is not just a nursing solution; it is an interprofessional team concept.
• Employ models and frameworks. These are critical to EBP. Having a model and/or framework that organizations can embrace to either implement or align with proprietary professional practice models makes a significant difference. Models and/or frameworks make transparent that this a way to apply EBP. Too often, EBP is thought of as a theoretical concept that is difficult to embrace, and that’s just not the case. Employing models and/or frameworks also engages clinicians and clinical scholars who are experts in their respective fields.
• Cultivate the right culture. If organizational culture simply accepts things the way they are and doesn’t question why, practice will never advance. Leaders that truly embrace cultures of EBP encourage their clinicians to ask why something is always done one particular way or another. Also, inquiry can bring about positive change. If a culture of inquiry does not exist in which people who don’t understand ask questions, practice will not change.

What if an organization has evidence-based tools but they are not immediately accessible to staff? This is a problem that exists in many organizations. Evidence-based tools are available, but the staff that cares for patients doesn’t always know where to find them. A solution to this problem is to integrate evidence-based decision-making into the Electronic Health Record (EHR) in a way that it is actionable for the clinician. To help bridge the gap between quality, safety and EBP, organizations need return on investment (ROI) tools to help make the case for why they should invest in areas such as care planning, methodologies that ensure nurses have the latest information, and help CFOs make the connection between these types of purchasing decisions and the bottom line. Also, know that these tools aren’t just for patient safety exclusively; they keep the clinicians safe as well.

EBP Opportunities and Challenges

Probably one of the greatest challenges and opportunities is applying EBP across the continuum of care. This is very much aligned with the Affordable Care Act and movement from fee-based to value-based service. Does it make sense for a patient with heart failure to receive care at an inpatient hospital setting that uses evidence-based guidelines and methodologies, to then be sent home and receive care at a heart failure clinic that doesn’t use an evidence-based approach to care?

There’s a great opportunity to establish EBP as a standard pillar across all healthcare settings to ensure the patient receives evidence-based, consistent care from all providers while engaging them in their own healthcare as well.

What’s Next for EBP?

Looking ahead, there are three ways in which EBP can be made a standard component of healthcare:

1. Make the evidence more evident in the workflow. This involves transitioning from documents that are static, to information that is actionable and evident to clinicians.
2. Facilitate integration with EHR vendors.  EBP must be integrated into health information technology in a way that makes it usable to clinicians in their day-to-day practice.
3. Continue to advance an interprofessional approach. Physicians who have primarily relied on clinical trials in the past are viewing evidence-based methodologies as additional options to arriving at quality-focused, value-based care. Along with nurses and other allied health professionals, they are beginning to adopt interprofessional EBP as a cornerstone to greatly improve the momentum of this movement.

Evidence-based practice can be a reality for all with the right tools, culture and patient engagement skills to help bring true patient value to the care process.

References

1. A Study of Chief Nurse Executives Indicates Low Prioritization of Evidence-Based Practice and Shortcomings in Hospital Performance Metrics Across the United States,” Worldviews on Evidence-Based Nursing, 2016; 13:1, 6-14.