1. The Importance of Evidence- Based Healthcare on Patient Safety Initiatives: The Way Forward Prof. Tawfik A.Khoja MBBS, MSc. Card., D.TQM. Dr. Abdulrahman Kamel MBBS, MSc. Card., D.TQM. Head of Technical Affair Dept. & H.C.Q. Advisor - GCC

2. Prof. Tawfik A.Khoja

3. ” أَفَمَن يَمْشِي مُكِبًّا عَلَى وَجْهِهِ أَهْدَى أَمَّن يَمْشِي سَوِيًّا عَلَى صِرَاطٍ مُّسْتَقِيمٍ ” “ Is then one who Walks headlong, with his face Grovelling, better guided, Or one who walks Evenly on a Straight Way ? ” سورة الملك ( آية 22) Holy Quran

4. Prof. Tawfik A.Khoja This presentation will try to answer the question: why Evidence-Based Health Care is a key component of Patient Safety? Through highlighting the following:  An overview of E.B healthcare.  Principles of E.B. Practice for Patient Safety.  Some important model of E.B. Practice.  Practice implications from Translation Science (demonstrate some of best Patient Safety Initiatives).

5. If we did not respect the evidence, we would have very little Leverage in our quest for the truth. Carl Sogan. say: produce your proof if ye are truthful. Holy Quran سورة البقرة ( آية 111) Prof. Tawfik A.Khoja

6. Evidence-Based Medicine Evidence-based medicine has become one of the major driving forces in the (National health system) NHS, with an impact on education, policy making, development and research. Prof. Tawfik A.Khoja

7.  "Evidence-based medicine (EBM) is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable patient-reported, clinician-observed, and research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments, and facilitate cost-effective health care". Source: McKibbon, K.A. et al. (1995) The medical literature as a resource for evidence based care. from the Health Information Research Unit, McMaster University, Ontario, Canada. Prof. Tawfik A.Khoja Evidence-Based Medicine

8. E.B Public Health. Brownson RC etal. 2003; Flowchart of evidence-based medicine Prof. Tawfik A.Khoja

9. Draws heavily upon the findings of scientific research (including social scientific research) that has been gathered and critically appraised according to explicit and sound principles of scientific inquiry. The opinions and judgments of experts that are based upon up-to-date scientific research clearly constitute high quality valid and reliable evidence. Evidence-based decision making Prof. Tawfik A.Khoja

10. Evidence Based Clinical Practice (EBCP)  EBCP  EBCP is an approach to health care practice in which the clinician is aware of the evidence that bears on her clinical practice, and the strength of that evidence". http://hiru.mcmaster.ca/ebm/default.htm#What_is_Evidence_Based_Medicine (McMaster University) Prof. Tawfik A.Khoja

11. Evidence-Based Health Care  Extends the application of the principles of Evidence- Based Medicine to all professions associated with health care, including purchasing and management". Centre for Evidence Based Medicine Glossary. http://cebm.jr2.ox.ac.uk/docs/glossary.html Prof. Tawfik A.Khoja

12. Evidence Based Healthcare  Current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factors.“ First Annual Nordic Workshop on how to critically appraise and use evidence in decisions about healthcare, National Institute of Public Health, Oslo, Norway, 1996.

13. Prof. Tawfik A.Khoja Karyn Baum, M.D. Assistant Professor of Medicine, University of Minnesota Why Evidence-based Medicine is a Key Component of Patient Safety One of the most important developments in patient safety has been the increasing recognition of the importance of evidence-based clinical practice. Evidence- based medicine (EBM) is the explicit integration of the best available scientific evidence into daily medical decision-making. More than that, it implies a culture of reflective, active, objective, and systematic medical practice.

14. Prof. Tawfik A.Khoja EBM encourages healthcare professionals to question their knowledge, consciously consider all options in patient care, seek out the scientific basis and evidence for those options, and integrate this new knowledge into care decisions in a rigorous and consistent manner. EBM also promotes the integration of individual expertise and patient values into the process of medical decision- making.

15. Prof. Tawfik A.Khoja A potent example of the ability of EBM to improve patient safety was demonstrated by the Agency for Healthcare Research and Quality (AHRQ) report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices2. This report reviewed the evidence regarding 83 patient safety-related practices currently in use by various components of the health care system. Remarkably, many of these practices are not supported by good evidence.

16. Prof. Tawfik A.Khoja Furthermore, many practices with proven evidence for effectiveness were found not to be routinely used. Clearly more work is needed to identify and adopt initiatives with proven efficacy and weed out practices that are not supported by evidence.

17. Prof. Tawfik A.Khoja In addition to translating the best evidence into safer health care system level interventions, it is equally important to support the translation of best science into individual clinical practice decisions. The field needs to take an interest in eliminating health care decisions that are unsupported by the best science and therefore increase the likelihood for errors.

18. Prof. Tawfik A.Khoja Training in and access to the tools of EBM will give healthcare teams the information and skills they need to make the best clinical decisions; evaluate specific patient safety interventions and more effectively design and test interventions.

19. Prof. Tawfik A.Khoja There are many ways healthcare leaders can support and sustain the use of evidence-based healthcare, which is an integral component of a “culture of safety”: (1)advocate for the use of evidence in making treatment and policy decisions.

20. Prof. Tawfik A.Khoja (2)ensure that there is the technical infrastructure necessary to support the daily practice of EBHC. In order to practice in an evidence-based manner, clinicians need ready access to the evidence at the point at which clinical decisions are being made. Sources, many of which are available on line, can be made available through hospital intranet and/or internet systems.

21. Prof. Tawfik A.Khoja (3)incorporate evidence-based healthcare concepts in assessing and evaluating healthcare setting performance in providing safe, high quality care. (4) Encourage and help support practitioners and your staff in maintaining current knowledge relative to their area of practice. In addition, assist them in disseminating this knowledge to others within the organization.

22. How research and evaluation evidence contributes to policy making Evidence is one factor that contributes to policy making, implementation and delivery. The following diagram indicates other important factors: Davies, P.T. 1999. Brit. Educ. Stud; 47(2): 108-121 Gray, J.A.M. 1997. EB Healthcare: How to Make Health Policy and Management Decisions Prof. Tawfik A.Khoja

23. Evidence-based practice (EBP) Best evidence includes empirical evidence from randomized controlled trials; evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion.

24. Prof. Tawfik A.Khoja When enough research evidence is available, the practice should be guided by research evidence in conjunction with clinical expertise and patient values. In some cases, however, a sufficient research base may not be available, and health care decision-making is derived principally from non-research evidence sources such as expert opinion and scientific principles. As more research is done in a specific area, the research evidence must be incorporated into the EBP.

25. Prof. Tawfik A.Khoja Models of Evidence-Based Practice Multiple models of EBP are available and have been used in a variety of clinical settings. Common elements of these models are selecting a practice topic, critique and syntheses of evidence, implementation, evaluation of the impact on patient care and provider performance, and consideration of the context/setting in which the practice is implemented.

26. Prof. Tawfik A.Khoja The learning that occurs during the process of translating research into practice is valuable information to capture and feed back into the process, so that others can adapt the evidence-based guideline and/or the implementation strategies.

27. Prof. Tawfik A.Khoja So, it extends the application of the principles of Evidence- Based Medicine to all professions associated with health care, including purchasing and management, which ultimately lead to enforce Patient Safety practices. Traditionally, Patient Safety research has focused on data analysis to identify Patient Safety issues and to demonstrate that a new practice will lead to improve quality and patient safety. Yet, only by putting into practice what is learned from research will care be made safer, appropriate and effective.

28. Prof. Tawfik A.Khoja Implementing evidence-based safety practices are not an option, but need strategies that address the complexity of systems of care, individual practitioners, senior leadership, and – ultimately – changing healthcare culture to be evidence-based practice environments.

29. Prof. Tawfik A.Khoja A definition for patient safety has emerged from the health care quality movement that is equally abstract, with various approaches to the more concrete essential components. Patient Safety

30. Prof. Tawfik A.Khoja “the prevention of harm to patients.” Emphasis is placed on the system of care delivery that: (1) prevents errors; (2) learns from the errors that do occur; and (3) is built on a culture of safety that involves health care professionals, organizations, and patients. Patient safety was defined by the IOM as:

31. Prof. Tawfik A.Khoja Patient safety practices Have been defined as “those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions.” This definition is concrete but quite incomplete, because so many practices have not been well studied with respect to their effectiveness in preventing or ameliorating harm.

32. Prof. Tawfik A.Khoja Many patient safety practices, such as use of simulators, bar coding, computerized physician order entry, and crew resource management, have been considered as possible strategies to avoid patient safety errors and improve health care processes; research has been exploring these areas, but their remains innumerable opportunities for further research.

33. Prof. Tawfik A.Khoja Evidence-based health care practices are available for a number of some clinical conditions such as asthma, heart failure, and diabetes. However, these practices are not always implemented in care delivery, and variation in practices abound. Traditionally, patient safety research has focused on data analyses to identify patient safety issues and to demonstrate that a new practice will lead to improved quality and patient safety. Overview of Evidence-Based Practice on PS

34. Prof. Tawfik A.Khoja Much less research attention has been paid to how to implement practices. Yet, only by putting into practice what is learned from research will care be made safer. Implementing evidence-based safety practices need strategies that address the complexity of systems of care, individual practitioners, senior leadership, and— ultimately—changing health care cultures to be evidence-based safety practice environments.

35. Prof. Tawfik A.Khoja Strategies for implementation include:  Using a change champion in the organization who can address potential implementation challenges.  Piloting/trying the change in a particular patient care area of the organization.  And using multidisciplinary implementation teams to assist in the practical aspects of embedding innovations into ongoing organizational processes. Steps of Evidence-Based Practice in PS

36. Prof. Tawfik A.Khoja Changing practice Takes considerable effort at both the individual and organizational level to apply evidence-based information and products in a particular context. When improvements in care as well as patient safety are demonstrated in the pilot studies and communicated to other relevant units in the organization, key personnel may then agree to fully adopt and sustain the change in practice.

37. Prof. Tawfik A.Khoja Once the EBP change is incorporated into the structure of the organization, the change is no longer considered an innovation but a standard of care.

38. Prof. Tawfik A.Khoja When viewing steps of the EBP process through the lens of an end user:  The process begins with selecting an area for improving care based on evidence (rather than asking what findings ought to be disseminated);  Determining the priority of the potential topic for the organization; formulating an EBP team composed of key stakeholders;  Determining if the evidence findings are appropriate for use in practice;  Writing an EBP standard specific to the organization;

39. Prof. Tawfik A.Khoja  Piloting the change in practice;  Implementing changes in practice in other relevant practice areas (depending on the outcome of the pilot);  Evaluating the EBP changes, and improvement in PS.  And transitioning ongoing quality improvement (QI) monitoring, staff education, and competency review of the EBP topic to appropriate organizational groups as defined by the organizational structure.  Integrate the work of EBP into the governance structure of the health care system;

40. Prof. Tawfik A.Khoja Leadership support is critical for promoting use of EBPs for PS. This support, which is expressed verbally, provides necessary resources, materials, and time to fulfill assigned responsibilities. Senior leaders need to create an organizational mission, vision, and strategic plan that incorporate EBP; Implement performance expectations for staff that include EBP work;

41. Prof. Tawfik A.Khoja A recent review of organizational interventions to implement EBPs for improving patient care and patient safety examined five major aspects of patient care.

42. Prof. Tawfik A.Khoja The review suggests that revision of professional roles (changing responsibilities and work of health professionals such as expanding roles of nurses and pharmacists) improved processes of care, but it was less clear about the effect on improvement of patient outcomes. Multidisciplinary teams (collaborative practice teams of physicians, nurses, and allied health professionals) treating mostly patients with prevalent chronic diseases resulted in improved patient outcomes.

43. Prof. Tawfik A.Khoja Integrated care services (e.g., disease management and case management) resulted in improved patient outcomes and cost savings. Interventions aimed at knowledge management (principally via use of technology to support patient care) resulted in improved adherence to EBPs and patient outcomes. The last aspect, quality management, had the fewest reviews available, with the results uncertain.

44. Prof. Tawfik A.Khoja Practice Implications From Translation Science Principles of Evidence-Based Practice for Patient Safety Several translation science principles are informative for implementing patient safety initiatives: Shojania KG, Grimshaw JM. Evidence-based quality improvement: the state of the science. Health Aff 2005;24(1):138-50.

45. Prof. Tawfik A.Khoja  First, consider the context and engage health care personnel who are at the point of care in selecting and prioritizing patient safety initiatives, clearly communicating the evidence base (strength and type) for the patient safety practice topic(s) and the conditions or setting to which it applies. These communication messages need to be carefully designed and targeted to each stakeholder user group.

46. Prof. Tawfik A.Khoja  Second, illustrate, through qualitative or quantitative data (e.g., near misses, sentinel events, adverse events, injuries from adverse events), the reason the organization and individuals within the organization should commit to an evidence-based safety practice topic. Clinicians tend to be more engaged in adopting patient safety initiatives when they understand the evidence base of the practice, in contrast to administrators saying, “We must do this because it is an external regulatory requirement.”

47. Prof. Tawfik A.Khoja  Third, didactic education alone is never enough to change practice; one-time education on a specific safety initiative is not enough. Rather, organizations must invest in the tools and skills needed to create a culture of evidence-based patient safety practices where questions are encouraged and systems are created to make it easy to do the right thing. Simply improving knowledge does not necessarily improve practice.

48. Prof. Tawfik A.Khoja  Fourth, the context of EBP improvements in patient safety need to be addressed at each step of the implementation process; piloting the change in practice is essential to determine the fit between the EBP patient safety information/innovation and the setting of care delivery. There is no one way to implement, and what works in one agency may need modification to fit the organizational culture of another context.

49. Prof. Tawfik A.Khoja  Finally, it is important to evaluate the processes and outcomes of implementation. Users and stakeholders need to know that the efforts to improve patient safety have a positive impact on quality of care.

50. Prof. Tawfik A.Khoja Evidence-Based Practices for Safe Patient Handling and Movement Efforts to reduce injuries associated with patient handling are often based on tradition and personal experience rather than scientific evidence. The purpose of this sudy is to summarize current evidence for interventions designed to reduce caregiver injuries, a significant problem for decades. Audrey Nelson, Andrea S. Baptiste

51. Prof. Tawfik A.Khoja Despite strong evidence, published over three decades, the most commonly used strategies have strong evidence that demonstrate they are ineffective. There is a growing body of evidence to support newer interventions that are effective or show promise in reducing musculoskeletal pain and injuries in care providers. The authors have organized potential solutions into three established ergonomic solution types: engineering based, administrative, and behavioral. For each intervention, the level of evidence to support its use is provided.

52. Prof. Tawfik A.Khoja e.g.: The chasm between current practice and scientific evidence is huge, when assessing interventions to prevent or minimize the risks associated with patient handling. A significant paradigm shift is needed in two areas: 1.Health care facilities need to stop using outdated approaches. The most common patient handling approaches in the United States include manual patient lifting, classes in body mechanics, training in safe lifting techniques and back belts.

53. Prof. Tawfik A.Khoja All of these approaches have been deemed ineffective in reducing caregiver injuries. These outdated approaches should be replaced with evidence-based strategies that include patient handling equipment/devices, patient care ergonomic assessment protocols, no lift policies, and patient lift teams. Promising new interventions, which are still being tested, include use of unit-based peer leaders and clinical tools, such as algorithms and patient assessment protocols.

54. Prof. Tawfik A.Khoja 2.A major change is needed in the current curricula in schools of nursing across the United States. The curriculum change needs to address evidence-based strategies and expose the nursing student to technologies available to reduce risk in the workplace. The American Nurses Association and the Veterans Health Administration have both embraced these new evidence-based approaches. It remains to be seen what resources will be mobilized to address this long-standing problem.

55. Prof. Tawfik A.Khoja Designing evidence-based patient safety interventions: the case of the UK’s National Health Service hospital wristbands Rationale, aims and objectives Current evidence suggests that hospital inpatient identification wristbands are not used optimally. Here we report a project by the National Patient Safety Agency (NPSA) to inform guidance development to hospitals regarding wristband specifications. Nick Sevdalis, et, al: Volume 15, Issue 2, April 2009

56. Prof. Tawfik A.Khoja Method A survey assessed : i.The information on wristbands; ii.The processes of issuing/ checking/applying wristbands onto patients; iii.The types/designs of wristbands (including colour- coding); iv.The main problems faced by staff face in relation to wrist banding patients.

57. Prof. Tawfik A.Khoja Results Responses from 166 staff members from 62 hospitals in England and Wales were collected. Information: most participants reported using the patients’ first and last names, their date of birth and their local hospital number. The National Health Service (NHS) number, which is a unique identifier for each patient, is used by 37% of the respondents. Issuing process: wristbands are issued on admission or at Emergency Departments.

58. Prof. Tawfik A.Khoja Trained or untrained staff are involved in issuing/checking/applying wristbands onto patients, without significant problems. Colour-coding: 29/36 multiple respondent hospitals and 15/16 single-respondent hospitals use colour-coded wristbands to indicate special patient status (e.g. allergies). Colour-coding is not used consistently: four colours are used to signal risk of fall; red is used to signal at least 10 different statuses/risks.

59. Prof. Tawfik A.Khoja Conclusion The NPSA recommends that wristbands should include patient’s last and first name, date of birth and NHS number. They should be printed/written in black against white background. Only red colour should be used to signal special patient status. These recommendations are consistent with current developments in patient identification, and will be evaluated.

60. Prof. Tawfik A.Khoja Integrating Evidence Based Practice into Patient Safety Manager Training DOD Patient Safety Solution Centre As part of its mission to foster a culture of safety throughout the Military Health System (MHS), the Department of Defense Patient Safety Program (DoD PSP) is responsible for the professional development of the MHS patient safety workforce.

61. Prof. Tawfik A.Khoja The DoD PSP convened a team of training specialists and subject matter experts to design a three-day program for entry-level Patient Safety Managers (PSMs), incorporating the latest evidence-based safe practices, research, and instructional techniques. The course design team used the ADDIE (Analyze-Design- Develop-Implement-Evaluate) Model for curriculum development with a continuous process improvement approach.

62. Prof. Tawfik A.Khoja A key objective of the Basic PSM Course was to build PSM competence around integrating EBP into their professional activities. Targeted Learning Outcomes For EBP: Participants are able to access the latest EBPs, integrate EBPs into their PSM activities, and evaluate impact using basic measurement tools and techniques.

63. Prof. Tawfik A.Khoja Teaching-Learning Activities Course pre-work: a Web search of evidence-based safe practices and the associated national healthcare quality and safety organizations. Interactive classroom lessons, led by subject matter experts, on various aspects of integrating EBP into PSM activities. Hands-on classroom activities, including development of individualized action plans or “roadmaps” for their next six months on the job. Follow-up coaching calls at 3, 6, and 12 months post- training for on-going performance support.

64. Prof. Tawfik A.Khoja Evaluation of Approach Evaluation incorporates the sciences of the Context-Input-Process- Product Model and the Kirkpatrick Four-Level model for program and training evaluation. Each course undergoes a multi-level evaluation conducted at periodic intervals, including assessments of participant reactions to training, learning, learning transfer to the job, and organizational barriers and enablers to learning transfer. Results show highly positive reactions to training, increased perceived competence in targeted PSM competencies (mean % PSMs with high confidence: 21.5% before training, 92.8% at 6- months post-training), and achievement of planned PSM activities over time.

65. Prof. Tawfik A.Khoja

66. In summary, To improve patient safety and the quality of care provided to our patients, we need to decrease clinical practice that varies from good scientific evidence, provide clinicians with ready access to the best possible clinical knowledge to aid in their medical decision- making, and arm them with the tools needed to assess and improve a hospital’s quality and safety systems and interventions.

67. Prof. Tawfik A.Khoja Assisting the physicians in implementing reliable knowledge is an important first step in building an evidence-based culture that ultimately leads to better and safer medical care for all the patients treated in healthcare fasciitis.

68. Prof. Tawfik A.Khoja In summary, Making an evidence-based change in practice involves a series of action steps and a complex, nonlinear process. Implementing the change will take several weeks to months, depending on the nature of the practice change. Increasing staff knowledge about a specific EBP and passive dissemination strategies are not likely to work, particularly in complex health care settings.

69. Prof. Tawfik A.Khoja Strategies that seem to have a positive effect on promoting use of EBPs include audit and feedback, use of clinical reminders and practice prompts, opinion leaders, change champions, interactive education, mass media, educational outreach/academic detailing, and characteristics of the context of care delivery (e.g., leadership, learning, questioning). It is important that senior leadership and those leading EBP improvements are aware of change as a process and continue to encourage and teach peers about the change in practice.

70. Prof. Tawfik A.Khoja The new practice must be continually reinforced and sustained or the practice change will be intermittent and soon fade, allowing more traditional methods of care to return.

71. Prof. Tawfik A.Khoja Conclusion Although the science of translating research into patient safety practice is fairly new, there is some guiding evidence of what implementation interventions to use in promoting patient safety practices. However, there is no magic bullet for translating what is known from research into practice. To move evidence-based interventions into safety practice, several strategies may be needed. Additionally, what works in one context of care may or may not work in another setting, thereby suggesting that context variables matter in implementation.

72. Prof. Tawfik A.Khoja داعياً الله سبحانه لي ولكم بدوام الصحة والعافية والرضوان