1. Delmar Learning Copyright © 2003 Delmar Learning, a Thomson Learning company Nursing Leadership & Management Patricia Kelly-Heidenthal 0-7668-2508-6

2. Delmar Learning Copyright © 2003 Delmar Learning, a Thomson Learning company Chapter 20 Strategies to Improve Patient Care Outcomes

3. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company3 Objectives  Upon completion of this chapter, the reader should be able to: Discuss the use of outcomes research in evidence-based practice. Describe selected evidence-based models. Utilize the PDSA cycle framework for achieving improvement to implement evidence-based practice for specific patient care situations. Identify resources available to generate outcomes/benchmarks for clinical practice.

4. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company4 Evidence-based Practice Improvement Defined  Evidence-based practice (EBP) is defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.  Evidence-based practice is also referred to as outcomes research.

5. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company5 Evidence-based Practice Improvement Defined  Its goal is to provide evidence about benefits, risks, and results of treatments so individuals can make informed decisions and choices to improve their quality of life, and to identify potentially effective strategies that can be implemented to improve the quality and value of health care.

6. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company6 Evidence-based Multidisciplinary Practice Improvement Models  Practice guidelines, pathways, or algorithms should not replace individualized patient care.  Evidence-based practice has a medicinal focus, while evidence-based nursing practice considers the individual needs and preferences based on nursing theory and research.  Various EBP models have been developed in health care.

7. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company7 University of Colorado Hospital Model  This model is an evidence-based multidisciplinary practice model.  It presents a framework for using various information sources to change or support practice.  Health care team members use current and valid research from sources such as journals, conferences, and clinical experts as the basis for clinical decision making.

8. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company8 University of Colorado Hospital Model  This model depicts nine sources of evidence: Benchmarking data Cost-effective analysis Pathophysiology Retrospective/concurrent chart review Quality improvement and risk data International, national, and local standards Infection control data Patient preferences Clinical expertise

9. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company9 Plan-Do-Study-Act (PDSA) Cycle  The cycle begins with a plan and ends with action based on the learning gained during the cycle. Plan: develop a plan to change or test a process. Do: implement the plan. Study: summarize what was learned. Act: determine what actual changes to make.

10. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company10 Plan-Do-Study-Act (PDSA) Cycle  This cycle, which can be applied to a system or an individual, is driven by three main questions: What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

11. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company11 Application of PDSA to Pain Management  What are we trying to accomplish? Reduce or alleviate patient’s pain.  How will we know that a change is an improvement? Patient will indicate that pain is relieved.  What changes can we make that will result in improvement? We can develop a protocol and other strategies.

12. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company12 Application of PDSA to Pain Management  Combine the PDSA model for improvement with JCAHO pain standards.  Identify location and quality of pain.  Document pain rating, degree of relief, and alleviating or aggravating factors.  Consult with other health care team members to identify, implement, and document best strategies that reduce, minimize, or alleviate pain.

13. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company13 Phases of Application of PDSA to Pain Management  Planning: multidisciplinary staff develops a plan to test the effects of changes.  Doing: nursing staff conducts a trial using new strategies and collects data.  Studying: data is collected and reviewed, and improvements and issues are identified.  Acting: nursing staff shares findings with multidisciplinary staff and decides whether to implement change or continue testing it. In either case, staff continues to look for ways to improve process.

14. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company14 Application of PDSA to Pressure Ulcer Management  What are we trying to accomplish? Treat and heal patient’s pressure ulcers. As part of this process, improve patient’s mobility and activity level.  How will we know that a change is an improvement? Ulcers show signs of healing; patient expresses less discomfort; patient demonstrates greater mobility and activity.

15. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company15 Application of PDSA to Pressure Ulcer Management  What changes can we make that will result in improvement? Initiate protocols and recommendations for treatment of open skin. Conduct multidisciplinary conference to coordinate strategies for pressure relief, skin care, mobility, and nutrition. Involve patient in development of goals and recommendations.

16. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company16 Phases of Application of PDSA to Pressure Ulcer Management  Planning: conduct multidisciplinary care conference, including patient in conference; identify and agree to changes in patient skin care and activity; provide measures to relieve patient pain and anxiety; develop and implement specific schedule of patient care, positioning, and activity.

17. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company17 Phases of Application of PDSA to Pressure Ulcer Management  Doing: implement plan of care; document status of skin breakdown and preventive interventions; physical therapist works with patient; nutritionist consults with patient.  Studying: assess healing progress of patient’s ulcers.  Acting: determine whether to change or continue treatment.

18. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company18 Application of PDSA to Wound Management  What are we trying to accomplish? Prevent wound infection & bleeding; control wound; promote patient  How will we know that a change is an improvement? Wound will decrease with no signs of infection.  What changes can we make that will result in an improvement? Consult wound care recommendations. Conduct multidisciplinary care conference to coordinate strategies. Coordinate wound care.

19. Chapter 20Copyright © 2003 Delmar Learning, a Thomson Learning company19 Phases of Application of PDSA to Wound Management  Planning: examine wound and recommend treatment regimen.  Doing: implement agreed-upon plan of care; monitor status of wound.  Studying: determine status of wound; evaluate comfort of patient.  Acting: determine whether to continue or revise treatment regimen.