Fluent Essays

Perspectives on Quality How do we learn about improving health care: a call for a new epistemological paradigm M. RASHAD MASSOUD1, DANIKA BARRY2, ANDREW MURPHY1, YVONNE ALBRECHT3, SYLVIA SAX4, and MICHAEL PARCHMAN5 1University Research Co., LLC., Bethesda, MD, USA, 2Harvard Medical School, Boston, MA, USA, 3Swiss Tropical and Public Health Institute, Basel, Switzerland, 4Institute of Public Health, University of Heidelberg, Heidelberg, Germany, and 5MacColl Center for Health Care Innovation, Group Health Research Institute, Seattle, WA, USA Address reprint requests to: Andrew Murphy, University Research Co., 7200 Wisconsin Avenue, Suite 500, Bethesda, MD 20814, USA. Tel: +1-301-828-3542; Fax: +1-301-941-8427; E-mail: [email protected] Accepted 10 March 2016 Abstract Purpose: The field of improving health care has been achieving more significant results in outcomes at scale in recent years. This has raised legitimate questions regarding the rigor, attribution, generalizability and replicability of the results. This paper describes the issue and outlines questions to be addressed in order to develop an epistemological paradigm that responds to these questions. Questions: We need to consider the following questions: (i) Did the improvements work? (ii) Why did they work? (iii) How do we know that the results can be attributed to the changes made? (iv) How can we replicate them? (Note, the goal is not to copy what was done, but to affect factors that can yield similar results in a different context.) Next steps: Answers to these questions will help improvers find ways to increase the rigor of their improvements, attribute the results to the changes made and better understand what is context specific and what is generalizable about the improvement. Key words: improvement, learning, complex adaptive systems, implementation, delivery Introduction This article raises an important issue in the field of improving health- care today: ‘How do we learn about improving healthcare, so that we can make our improvement efforts more rigorous, attributable, generalizable and replicable?’ (See Fig. 1). Intended to outline what we know and what remains to be answered, the article repre- sents a synthesis and analysis of the knowledge and experiences of the authors and reviewers. Although we acknowledge that the improvement community’s opinions differ regarding the definition of certain terms, this article is framed by the working definitions found in Table 1. The paper concludes with key questions that need to be addressed in order to advance the field of healthcare improvement. Background The World Health Organization (WHO) describes quality care as care that is effective, efficient, accessible, acceptable, patient-centered, equitable and safe [1]. Yet, much of the care received in high-, middle- and low-income settings does not meet the WHO criteria, often due to the complexity of healthcare―which is why we need to improve healthcare [2]. For the purposes of this paper, we will use the following working definition for improving healthcare: ‘The actions taken to en- sure that interventions established to be efficacious are implemented effectively every time they are needed.’ The multi-level structure found in healthcare settings exists as in- terconnected sets of autonomous healthcare providers, teams and units within healthcare organizations, nested within health systems. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/ 4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] International Journal of Quality in Health Care, 2016, 28(3), 420–424 doi: 10.1093/intqhc/mzw039 Advance Access Publication Date: 26 April 2016 Perspectives on Quality 420 D ow nloaded from https://academ ic.oup.com /intqhc/article/28/3/420/1750542 by guest on 13 S eptem ber 2021 http://www.oxfordjournals.org http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ The dynamic human interactions between and among healthcare work- ers, patients, managers, payers and other actors and the variety of so- cial, cultural, economic, historical, political and other factors within this multi-level structure put improving health care squarely in the arena of complex adaptive systems [3]. Complex adaptive systems are comprised of individuals who learn, self-organize and evolve in re- sponse to changes in their internal and external environment, and inter- relate in a non-linear fashion to accomplish their work and tasks [3, 4]. These complex adaptive systems, in which implementers operate, pre- sent unique challenges. They cannot be reduced to their component parts without the risk of negating the original intention of the interven- tion, therefore interventions must be implemented in a contextually adaptive manner in order to effectively work in any given system. The issue The field of improving health care has evolved to address the complex, interdependent, systemic nature of healthcare challenges, particularly through the use of adaptive, iterative testing and implementation of changes, and by empowering teams to use data in real time to do so. Teams and individuals who learn in these complex, adaptive systems use real-time data to assess whether introduced changes lead to an improvement in the outcome of interest—after which, they institute, adapt or discard these changes as needed, in a continuous cycle of testing and learning. This process is demonstrated in the example in Fig. 2. Improvements like these have generally relied on the use of time- series charts, which plot indicators of the improvement sought against frequent (daily or weekly) time intervals before, during and for a time period following the introduction of changes. At times, they have also used control limits, but as a rule, improvement has relied on analytic sta- tistics, as opposed to enumerative statistics, to establish significance [5]. Improving healthcare engages all key stakeholders involved in the outcome of interest, including healthcare providers directly involved in delivering care, together with their supervisory and support struc- tures, as required. This process can also include patients, families, com- munities and other stakeholders. By meaningfully engaging all key stakeholders, health teams are able to address systems and micro- and macro-political human-factors issues [6] and build ownership through restructuring processes. In addition, the adaptive, iterative nature of testing and learning allows the teams to implement changes appropriate to the local context and responsive to emergent and shifting dynamics among different actors and at various levels of the system. Over the past two decades, the application of modern improve- ment methods has expanded beyond the administrative processes in facilities, where it was first applied (for example, to reduce waiting times) to include clinical improvements (like reducing the incidence of hospital-acquired infections) and more significant improvements in health care (like reducing secondary complications and decreases in mortality); and, moreover, achieving these outcomes and results at scale [7, 8]. This evolution has generated greater interest in improve- ment and simultaneously raised more questions regarding the validity, rigor, attribution, generalizability and replicability of the results. In response to these legitimate questions, there have emerged two schools of thought. One school of thought calls for continuing to accept analytic statistics as sufficient evidence for improvement [5]. The other calls for subjecting improvement to the same enumerative statistical methods used in clinical research, such as the use of rando- mized control trials. Discussion The use of randomized controlled trials, the gold standard for clinical research, has been limited in the field of improving health care. In part, Figure 1 Codifying improvement. 421Learning about improving healthcare • Quality Improvement D ow nloaded from https://academ ic.oup.com /intqhc/article/28/3/420/1750542 by guest on 13 S eptem ber 2021 this is because randomized controlled trials often presume a linear, mechanistic system; however, improvement takes place within com- plex adaptive systems, which do not lend themselves neatly to this type of study. Furthermore, as illustrated in Fig. 1, our interventions must necessarily adapt to the context, which is often at odds with the conceptualization of improving health care as a fixed set of activ- ities which can be studied through controlled trials [9]. Other con- straints for the use of randomized, controlled trials include donor and host-country government constraints and ethical issues regarding randomization of interventions with proven efficacy, particularly, for those in low- and middle-income country settings [10, 11]. Improving health care is the act of taking an efficacious intervention from one setting and effectively implementing it in different contexts. It is this key element of adapting what works to new settings that sets im- provement in contrast to clinical research [12, 13]. The study of these complex systems will therefore require different methods of inquiry. Such methods may include, but are not limited to, stepped-wedge de- signs, comparison groups with calculations of difference-in-difference, qualitative evaluations to understand why and how the interventions worked, and the use of mixed-methods’ approaches, including random- ization and observation. Toward this end, there is a need not only for evidence-based practice, but also for ‘practice-based evidence’—which is relevant to the stakeholders responsible for implementation—and for systems that allow for rapid learning in order to build this knowledge. This knowledge may be generalizable or may need further adaption for a different context [14]. A 2015 literature review by Portela et al. [15] provided a useful overview of various methods that can be used to learn about improv- ing health care and describes the strengths and weakness of various approaches that range from more traditional, experimental designs to quasi-experimental designs, as well as systematic reviews, program and process evaluations, qualitative methods and economic evalua- tions. The authors note that the dichotomy between designs classified as practical (‘aimed at producing change’) and those classified as sci- entific (‘aimed at producing new knowledge’) may be a false one, and that the field should find ways to optimize rigor and generalizability of studies, without compromising the importance of adaptability and context. On this note, Davidoff et al. and other authors call for the demys- tification of the use of theory in improving health care [16], including more use of theory a priori to better understand how and why an improvement occurs and provide insight into the so-called ‘black box’ of improvement. Parry et al. provide a guide for a formative, theory-driven approach to evaluating improvement initiatives by Table 1 Key terms Key term Definition Process The sequence of steps that converts inputs from suppliers to outputs for recipients. All work can be represented in the form of processes: clinical algorithms, patient materials, information flow. More often, processes of care delivery represent flows of several of the aforementioned types. System The sum total of all processes and other elements aimed at producing a common output. One can view the system of care in an HIV clinic as all the care processes that go into caring for patients with HIV. Improving healthcare The actions taken to ensure that interventions established to be efficacious are implemented effectively every time they are needed. Complex adaptive system (CAS) A CAS is comprised of individuals who learn, self-organize, evolve in response to changes in their internal and external environment, and inter-relate in a non-linear fashion to accomplish their work and tasks [3, 5]. Time-series charts Time-series charts are a graphical presentation of an indicator over time and are a common tool used to track continuous-quality-improvement data. Statistical process control was developed by Shewhart [28] and popularized by Deming [29] as a way to apply statistical methods to distinguish between natural or ‘common cause variation’ in a process (i.e. random variation that could be computed from a statistical model based on the Gaussian, Poisson or binomial distribution), versus ‘special cause variation,’ which is variation that follows certain defined patterns (e.g. 2 out of 3 successive points >2 SD from the mean) [30]. This adaptation of traditional statistical hypothesis testing into easily visualized tests is a practical way to add rigor to the interpretation of time-series charts. Figure 2 The aim of the improvement was to increase the proportion of HIV patients who received middle-upper arm circumference (MUAC) measurement in order to identify malnourished patients, and improve their nutritional status. The initial changes were to have nurses and physicians complete a nutrition-assessment training, provide them with the MUAC tapes, and ask them to measure and record the MUAC. However, these did not result in any improvement for the first few weeks (Graph 1). Then they achieved nearly 100\% during the week of an external visit from the Ministry of Health, but this was not sustained. At this point, the health center engaged an improvement advisor to work with them. He set up a team comprised of the individuals who played roles in the process of care for HIV patients: receptionist, nurse, physician, pharmacist, and patient representative. They decided they would assess their progress on a weekly basis, using a time-series chart. The team decided to implement another change: to appoint one nurse to be in charge of performing MUAC right after registration. This led to an improvement of approximately 70\%. The team discovered that patients skipped the MUAC station to be seen by the physician, or missed the nurse while she was out for a break. The team decided to test another change: involve expert patients in MUAC at the registration desk, including training them in MUAC measurement. This led to an improvement of approximately 90\%. [Example from USAID Health Care Improvement Project (2007–2014)]. 422 Massoud et al. D ow nloaded from https://academ ic.oup.com /intqhc/article/28/3/420/1750542 by guest on 13 S eptem ber 2021 defining three improvement phases for initiatives (innovation, test- ing, and scale up and spread), each defined by the degree of belief in the intervention, and each requiring a different evaluation approach [17]. Campbell et al. [18] also emphasize the importance of phasing; for example, in the use of randomized controlled trials for complex inter- ventions. The authors describe a more flexible approach to the 2000 Medical Research Council framework [19] on this topic by consider- ing an iterative, stepwise approach to building understanding of the context of the problem, intervention and evaluation, in order to obtain meaningful information from randomized, controlled trials of com- plex interventions. Braithwaite et al. urge improvement teams to learn from the way clinicians adjust their behavior with their concept of Safety II: ‘[w]e must understand how frontline staff facilitate and manage their work flexibility and safely, instead of insisting on blind compliance or the standardization of their work’ [20]. Others have called attention to different ways to integrate adapt- ability with the fixed concept of randomized, controlled, trial interven- tions (delineating between standardization of, but not the form of, the intervention) [21] and the need for earlier pilot testing with iterative learning and non-linear evaluation processes, in order to more fully understand complex adaptive systems [22]. Furthermore, as a social intervention, improving health care is complex and, therefore, difficult to understand, design, implement, reproduce, describe and report. Frameworks, such as the Consoli- dated Framework for Implementation Research, developed by Damschroder et al. [23], provide guidance for ways to evaluate com- plex adaptive systems by classifying them into various domains, which describe various intervention and contextual factors relevant to the evaluation. The Template for Intervention Description and Replication (TIDieR) guidelines developed by Hoffmann et al. [24] and the Standards for Quality-Improvement Reporting Excellence (SQUIRE) Guidelines [25] provide a guide for improved reporting of interventions in order to improve the completeness of reporting and aid replicability [26]. Advancing the field: issues that need to be addressed The work presented by the above-mentioned authors is rooted in the ideas of showing that improvement has occurred, why it has occurred, and how to better learn about improvement to make it happen more effectively and in other contexts. There is evidence to support these objectives and we must build upon this to move improvement forward. These are also the themes that lead us to the next level of questions for improvement. In order to learn about improving health care, there is a need for thought leaders in improving health care, as well as from related fields that also use complex adaptive systems; researchers; and others to come together to co-develop a robust framework that has widespread support and that reflects the diverse, nuanced ways we learn about im- proving health care. Many questions remain to be answered. These include, but are not limited to: • Can we attribute the improvements we are measuring to the changes we are testing and implementing? • How do we know that no other factors are influencing the results— for example, other changes of which we are not aware, or secular trends? • If other factors are also affecting the results, how do we know what part is attributable to the changes we are making? • Why did the changes which yielded improvements work, and how? • If we obtain good results, and have documented the changes which yielded them, to what extent can we implement them elsewhere with the same fidelity and expect to get similar results? • What elements of an improvement are transferable, and what adaptations are needed? • How can we incorporate the effects of local context into the im- provements? • How should we design improvement efforts to answer different learning objectives? • How do we optimize data collection that simultaneously serves to drive quality improvement, inform evaluation efforts, and fulfill performance reporting requirements? Answers to these questions will necessarily lead to multiple study types, depending on what we want to learn, in what context, and for what purpose. A phenomenon that is relevant to learning in general which also equally applies to improving health care, is that successful work which produces results tend to get published. Learning comes from not only what has worked and why, but also what has not worked and why not. In order to enhance learning we need to be deliberate about studying not only success, but also failures. The changes which failed, why they did not work and under what circumstance [10, 27]. Why/so what A new framework for how we learn about improvement will help in the design, implementation and evaluation of improving health care to strengthen attribution and better understand variations in effective- ness through reproducible findings in different contexts. This will in turn allow us to understand which activities, under which conditions, are most effective at achieving sustained results in health outcomes. Conclusion The complexity of health care requires a more rigorous approach to advance our understanding of methods for learning about improving health care. Additionally, the greater use of robust qualitative, quan- titate and mixed methods is needed to assess effectiveness—not merely to demonstrate if an intervention works, but why and how it works— and to explore the factors underlying success or failure. Key questions to examine further include how to strengthen the rigor of the improvement; increase attribution of results to the changes tested; provide better balance to the often opposing needs of improv- ing fidelity of the intervention, versus allowing for adaptation; make conclusions that are generalizable, but that also respond to the local context; and account for political considerations in improvement activities. This can lead to an improved epistemological paradigm for improvement. Acknowledgements The authors would like to acknowledge the contributions of a number of reviewers who guided this manuscript: Bruce Agins, Brian Austin, Don Gold- mann, Frank Davidoff, Jim Heiby, Lani Marquez, Michael Marx, John Øvretveit, Alex Rowe and Alexia Zurkuhlen. 423Learning about improving healthcare • Quality Improvement D ow nloaded from https://academ ic.oup.com /intqhc/article/28/3/420/1750542 by guest on 13 S eptem ber 2021 References 1. World Health Organization. Quality of Care: A Process for Making Strategic Choices in Health Systems. World Health Organization, 2006. 2. Holloway KA, Ivanovska V, Wagner AK et al. Have we improved use of medicines in developing and transitional countries and do we know how to? Two decades of evidence. Trop Med Int Health 2013;18:656–64. 3. McDaniel RR, Driebe DJ. Complexity science and health care management. Adv Health Care Manage 2001;2:11–36. 4. Capra F. 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Out of the Crisis. Cambridge, MA: Massachusetts Institute of Technology Center for Advanced Engineering Studies, 1986. 30. Benneyan JC, Lloyd RC, Plsek PE. Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care 2003;12: 458–64. 424 Massoud et al. D ow nloaded from https://academ ic.oup.com /intqhc/article/28/3/420/1750542 by guest on 13 S eptem ber 2021 02-mzw044 03-mzw024 04-mzw019 05-mzw016 06-mzw017 07-mzw020 08-mzw023 09-mzw025 10-mzw029 11-mzw037 12-mzw030 13-mzw036 14-mzw038 15-mzw028 16-mzw031 17-mzw042 18-mzw045 19-mzw046 20-mzw047 21-mzw027 22-mzw041 23-MZW021 24-mzw032 25-mzw039 EBP Journal Article in APA format: Massoud, M. R., Barry, D., Murphy, A., Albrecht, Y., Sax, S., & Parchman, M. (2016). How do we learn about improving health care: A call for a new epistemological paradigm. International Journal for Quality in Health Care, 28(3), 420-424. https://doi.org/10.1093/intqhc/mzw039 Is the article Evidence Based? Name of the journal and year of publication Yes Name: International Journal for Quality in Health Care Year: 2016 State the problem and the goal of the project Does this project correlate with your problem? How? What are you trying to achieve? Does the article support the goal? Problem: Delays in Orthopedic and Neuro-Surgical units. This leads to high rates of mortality as a result of limb and joint complications not being attended on time. Goal: the goal of this project improve the quality of care provided to patients by proposing a plan where the units will cover staffing for every other’s peak days. The plan proposal: Monday and Wednesday: both orthopedic surgeons and neuro surgeons be present in the hospital since this is a peak day. Tuesday: Orthopedic surgeons Wednesday: None Thursday: both orthopedic surgeons and neurosurgeons Friday: neurosurgeons Pairing such surgeons will enhance efficiency since the patients will not have to wait until Thursday for the neurosurgeons to come. This well help in ensuring that all kinds of interventions developed to be efficacious are executed effectively when needed. The goal of our project is to propose a plan that will increase the quality of care provided to patients, promote patient satisfaction and improve the morale of the staffs. The article is significantly related to our project since it aims also at improving the complexity settings in health facilities in order to the quality of care. The major focus of our project is to reduce the time patients have to wait in order to get treatment. our project proposes that both professionals to be available three times a week to enhance efficacy. Strengths What is good about the article? Support: our project has been supported by various parties who I believe were of greater impact to the progress of the project. It was also supported by the administration as well as the orthopedic groups in the hospital. The orthopedic surgeons were empowered to enhance their quality of care through changes from the project. The orthopedic groups were of great help since it made it easy to determine what they are doing now that could be wrong and how it can be changed to better patient care. This help to gauge analyze they opinions about the proposal before implementation. It helped in incorporating their ideas in coming up with a plan that will be implementable in the ground and not in paper. Another strength for the project is that it is fully funded by the health facility hence all types of resources were not a challenge to the project. Many projects fail due to lack of resources as well as inefficiencies. The leadership style of the project team was bottom top approach. This help to form a good plan based on opinions from the two units themselves and then presented to the executive team for approval. Since the executive are part of the project, consulting them in the progress ensured that the project was in the right direction and the end product will be ready for approval. The collaboration in the project reduces the chance of the plan facing resistance in the two outlined units in the hospital. Implementation areas? NO, our project was executed in Orthopedic and Neuro-Surgical units while the one in the article was implemented in epistemological units. Internal weaknesses Compliance: Based of the researcher’s findings, it was challenging for some staffs to comply with the new changes since they had gotten used the previous routines. most of them stated that this schedule would compromise a lot of their plans. They insisted that this kind of schedule would make them spend a lot of time in the hospital making them neglect their social life. Therefore, some were not ready to buy inn the idea. Time: there was no enough time to carry out study in various units since it could exceed the time allocated for the project. The makes it questionable on whether the results are reliable to be applied in other units where most of the individuals were not involved in the project. External opportunities Care improvement: The results of the study revealed that the Orthopedic and Neuro-Surgical professionals could reduce times patients had to wait for them to be available in the hospital. this would also reduce congestion of patients throughout the weak since they have been added an extra day where they can visit the surgeons. The researchers also should have measured the level of satisfaction for the patients in order to determine whether whey are happy with the new changes. Satisfaction of the staffs in the two units: the researchers discovered that there is a significant difference in the number of patients visiting every day since they were now distributed in three days. This reduced a lot of pressure on the surgeons on the days there are at work. Threats Reliability: this is the major threat in the project outcomes since the project focused in Orthopedic and Neuro-Surgical units while carrying out the study. Therefore, it is not easy to determine whether the results are applicable in other units such as emergency department, intensive care unit and cardiac care unit. Time: most of the staffs complain that most of them will lack time to be with their families and exercise their social life. This is because most of them will tend to stand in for others to reduce waiting time for patients. Some of them tend to resign the job due to the new schedule. Implementation Through: The Transtheoretical Model: Stages of Change  Precontemplation Discuss report issues with charge nurses and harvest nurses, asking them for ideas. Contemplation Charge and harvest nurses sit with knowledge of the problem. Offer them research on SBAR. Present plan to stake holders. Invite CNO, directors, harvest nurses and PCTs. Preparation Supply staff with SBAR templates, offer in-services on SBAR communication education, and educate on SBAR during pre-shift meetings.   Action Implement SBAR template during hand-off report. Maintenance Continue buy-in from harvest nurses and other staff by asking them to help personalize the form for the unit Set performance goals related to hand-off associated errors. Highlight problems related to hand-off report during pre-shift report and how SBAR could circumvent those. PDF- page 96 management theory  PDF- page 107 leadership theory Precontempemplation: Nurse manager goes to charge nurses, harvest nurses, and harvest support staff with the SBAR template and asks them to sit with it for one week. He or she will ask for feedback from these individuals about implementing it on the unit.  Contemplation: Harvest nurses and support staff, and charge nurses spend a week with the SBAR template and consider its strengths, weaknesses, and or simply form an opinion around it.   Preparation: nurse manager introduces in-services on SBAR and charge nurses begin introducing the template during pre-shift meetings.  Action: Nurses and support staff begin using the template during all hand-off reports for a one month period. Nurse manager seeks input from harvest staff on ways to improve the system and attempts to include their input on a trial period, thereby extending the practice of the original SBAR for another month with most staff, and offering a personalization to those interested in improving the system.  Maintenance: Nurse manager compares statistics from the same time period one year ago, to the same length of time prior to using the SBAR report, and the data from the SBAR report compared with the modified SBAR report and presents the data to the staff at a staff meeting. At the meeting the nurse manager encourages public input and opinions on the SBAR report. If there is resistance, the manager asks that SBAR be continued in practice for a 3 month period in which he or she will personally receive report from individuals on their patients – helping those nurses who need it with ways to be more succinct. At this point, the report will have been used in practice for 5 months and will have become habit for many of the staff.  1 Evaluation Desired Outcome Actual Outcome  Maintain Goals and Desired Outcomes Lower amount of time giving report by < 45 minutes Implement standardized SBAR throughout the unit, structuring the process  Nurses will be able to demonstrate standardized process of hand-off report Statistical significance in decreasing the rate of communication errors that leads to errors in patient care Amount of time giving report has decreased by using a standardized process (Stewart & Hand, 2017)  Standardized process of giving report increased efficiency of verbal communication (Stewart & Hand, 2017)  Decrease in the rate of callbacks for information clarification (Robins & Dai, 2017) Use of the SBAR tool during handoffs in a quasi-experimental study decreased the proportion of incident reports related to misunderstanding, misinterpretation, or omission of information from 31\% to 11\% (Stewart & Hand, 2017 Provide continuous education throughout clinical experience on usage of the standardized process of giving report (Stewart & Hand, 2017)  Standardized process for reporting reduces hierarchical barriers (various career stages) increases confidence of the users, decreases length of report time and accuracy of exchanged information. (Stewart & Hand, 2017) - Use of the SBAR tool during handoffs in a quasi-experimental study decreased the proportion of incident reports related to misunderstanding, misinterpretation, or omission of information from 31\% to 11\% (Stewart & Hand, 2017) -Discuss if this is successful and why? The reasons Nurses are encouraged to seek new ways to implement best practices as they work (Eberhardt, 2014)  2 Implementation Barriers Medical personnel have personal bias on giving report (Ghosh et al., 2018)  Different nurses have different approaches to how they perform report (Ghosh et al., 2018) Some staff are unreceptive to change (Robins & Dai, 2017) and it is difficult to [enforce a] change in practice for long time staff (Eberhardt, 2014)  Majka - Our 3 main hurdles that prevent implementation is different nurses give report in different ways and personnel being biased with giving report, as well as, some staff dont want to change their styles of giving report such as more seasoned nurses that have been in the profession for many years. With that being said here are some questions to think about... 3 Questions to Think About Why is SBAR preferred to personalized hand off reporting? What limitations do you think SBAR represents when giving report? Is it more beneficial to use a single standard SBAR tool or to personalize the tool to match specific units? Why?  Assignment: From the article, deduce the following:  Implementation, Evaluation, Implementation Barriers, and  Questions to Think About, using the exemplar as a guide. 1) Implementation Through: The Transtheoretical Model: Stages of Change  · Precontemplation · Discuss report issues with charge nurses and harvest nurses, asking them for ideas. · Contemplation · Charge and harvest nurses sit with knowledge of the problem. Offer them research on SBAR. · Present plan to stake holders. Invite CNO, directors, harvest nurses and PCTs. · Preparation · Supply staff with SBAR templates, offer in-services on SBAR communication education, and educate on SBAR during pre-shift meetings. · Action · Implement SBAR template during hand-off report. · Maintenance · Continue buy-in from harvest nurses and other staff by asking them to help personalize the form for the unit · Set performance goals related to hand-off associated errors. · Highlight problems related to hand-off report during pre-shift report and how SBAR could circumvent those. Evaluation Desired Outcome Actual Outcome  Maintain Goals and Desired Outcomes · Lower amount of time giving report by < 45 minutes · Implement standardized SBAR throughout the unit, structuring the process  · Nurses will be able to demonstrate standardized process of hand-off report · Statistical significance in decreasing the rate of communication errors that leads to errors in patient care · Amount of time giving report has decreased by using a standardized process (Stewart & Hand, 2017)  · Standardized process of giving report increased efficiency of verbal communication (Stewart & Hand, 2017)  · Decrease in the rate of callbacks for information clarification (Robins & Dai, 2017) · Use of the SBAR tool during handoffs in a quasi-experimental study decreased the proportion of incident reports related to misunderstanding, misinterpretation, or omission of information from 31\% to 11\% (Stewart & Hand, 2017 · Provide continuous education throughout clinical experience on usage of the standardized process of giving report (Stewart & Hand, 2017)  · Standardized process for reporting reduces hierarchical barriers (various career stages) increases confidence of the users, decreases length of report time and accuracy of exchanged information. (Stewart & Hand, 2017) 3) Implementation Barriers · Medical personnel have personal bias on giving report (Ghosh et al., 2018)  · Different nurses have different approaches to how they perform report (Ghosh et al., 2018) · Some staff are unreceptive to change (Robins & Dai, 2017) and it is difficult to [enforce a change in practice for long time staff (Eberhardt, 2014)  4) Questions to Think About · Why is SBAR preferred to personalized hand off reporting? · What limitations do you think SBAR represents when giving report? · Is it more beneficial to use a single standard SBAR tool or to personalize the tool to match specific units? Why?  TOPIC: Unit pairing to meet staffing needs :  The Orthopedic and Neuro-Surgical units of a hospital have varying censuses.  The Orthopedic surgeons operate at this hospital on Monday and Tuesday while the neurosurgeons operate on Thursday and Friday.  It has been decided that the units will cover staffing for each other’s peak days.  Your task is to propose a plan that will assure quality care, staff morale, and patient satisfaction will remain high with this change. Individual EBP Project Analysis The Individual EBP Assignment requires the learner to find an EPB article that relates to the topic and group project problem. below you find documents to help you with this assignment: EBP Article Analysis Guideline.docx Exemplar.EBP.docx EBP Journal Article PowerPoint Instructions.pptx · First review the group project problem and title. · Use keywords from your problem for your lookup inquiry. i.e. infection control, nurse, retention, etc.  · Use EBP articles no more than 8 years old.  · Make sure you put your name at the top and include your article citation in 7th ed. APA format of your assignment - see exemplar.  · There are prompts in the left column to assist you.  · Do not give research terms on your assignment i.e. this is a cross-sectional study or has validity unless youre ready to explain how this will help you solve your problem. These terms are used so that you know if an article is valid and reliable. OK, so now that you found this, your job is to find out how this project will help you solve your problem.  · The paper is set up to determine the strength, weaknesses, opportunities, and threats of the project itself.  · By answering these questions, you will help guide and collaborate with your peers with constructive feedback on how to solve your problem collectively as a team. · Strength - Example: Did they have the support of the peers, manager, CEO. Did this project improve patient satisfaction, quality, efficiency? Usually found in the literature review and results. · Weakness - Example: This is the opposite. Why was this plan weak: Not enough education, no support, not enough money because of the expense? Usually found in the problem of the literature review, results, and limitations. · Opportunity - Example: If there wasnt enough education, is this an opportunity? A better survey or tool? Usually found in results or limitations and future implications. · Threat - Example: Increased infection, possible death, etc. Usually found in the literature review.  · It is your job to know your article and have the ability to articulate what your article is about with your peers and with your instructor.  · During the virtual class, you may be asked to elaborate on your article. So know your article!  · Please note that the exemplar provided received maximum points.