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

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),

18. Examples of Strategies
Planning
Education Strategies
Finance
Restructure Strategies
Quality Management Strategies
Conduct needs assessment
Train-the-trainer
Alter incentives
Revise roles
Small tests of change
Involve executive board
Learning collaborative
Access new funding
Change physical structure
Audit-feedback
Visit other sites
Local opinion leaders
Create new service teams
Improvement advisor
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
Communication

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

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

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 Skin-to-skin contact at birth
# 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

33. Critical X’s Solution Supplementation with non-human milk
Follow provider orders not to supplement breastfed newborns without first notifying provider. Documentation of informed decision or medical indication for supplementation with non-human milk. Education to providers, nurses and parents on indications for supplementation.
Limited skin-to-skin contact at birth
Implement evidence-based practice of Skin-to-skin contact at birth

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 s
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), Rogers, E.M. (2003). Diffusion of Innovations. New York : Free Press. Titler MG, & Everett, L. Q. (2001). Translating research into practice. considerations for critical care investigators. Critical Care Nursing Clinics of North America, 13(4), Titler, M. G. (2010). Translation science and context. Research & Theory for Nursing Practice, 24(1), doi: / 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), doi: /