Changing Practice the Easy Way

1. Changing Practice the Easy Way Integrating quality & translational research models Peggy Brown DNP, RN, APRN-CNS-BC, NE-BC Clinical Quality Coordinator The Nebraska Medical Center

2. Objectives • Identify gaps between evidence and practice • Recognize the role of Translational Science in improving quality of care • Describe one strategy/technique that you could use to facilitate a practice change

3. Here a gap, there a gap, everywhere a gap, gap

9. Close the gap

10. Meet your Neighbor Share your experience with a GAP 3 minutes

11. FOLLOW A MAP

12. http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

14. Translational science • “Diffusion & implementation” • “Knowledge translation & integration”

15. Dissemination of evidence Researcher User Practice guidelines Publications Tool kits Presentations

16. Implementation of Evidence User patient

17. 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.

18. Examples of Strategies Powell et al. (2012)

19. FOLLOW A MAP

20. Translational Research Model Titler & Everett(2001)

21. Characteristics of the Evidence-based practice/Innovation • Advantages • Compatibility with values and needs • Complexity • Feasible • Cost Titler (2008)

22. Communication • 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

24. Users • Stakeholders • Adoption of practice varies • Audit and feedback changes behavior • Opinion leaders • Change agents

25. Social System • Organizational resources • Organizational size • Organizational culture • Readiness for change • Structure supporting EBP • Leadership support

26. implementation Example EBP: Uninterrupted skin-to-skin contact at birth Map: Integrated quality improvement and translational research model

27. Define Measure Analyze Improve Innovation Communication Social System Users Control Feedback Feedback Adoption

28. 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.

29. 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

30. Measures Exclusive 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

31. Analyze Supplementation • 50% of breastfed newborns were supplemented with non-breastmilk (Jan’13) Skin-to-skin contact (SSC) at birth • Literature 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)

32. Analyze Benefits of skin-to-skin contact at birth • Physiologic stability • Respirations, temperature, glucose levels, decreased crying & stress • Promotes attachment behaviors • Short-term and long-term • Increased exclusive breastfeeding in hospital • Longer duration of breastfeeding

34. 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

35. Improve - Communication Increase understanding of advantages of innovation • You-tube videos of SSC • Emails • Links to websites • Research abstracts • Unit meetings • Class for professionals • One-to-one discussions with change champions/opinion leaders • Bulletin boards

36. Improve - Users • Nurses & Providers • Opinion leaders • Change champions

39. Improve – Social System Provided structure for innovation: • Shared governance structure • Quality triad • Policy/procedure

40. Control – July 2013 • Audit-feedback • Skin-to-skin contact weekly, individual • Monthly exclusive breastfeeding %

42. Control – January 2014 • Monthly/Quarterly skin-to-skin percentages • Feedback for individual trends • 10th percentile – Are we there?

43. Share with your Neighbor Strategy you may use to enhance implementation of the next evidence-based practice 3 minutes

44. Objectives • Identify gaps between evidence and practice • Recognize the role of Translational Science in improving quality of care • Describe one strategy/technique that you could use to facilitate a practice change

45. 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. TitlerMG, & 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