Evidence-based practice is a proven approach for hospitals as well as individual physicians and nurses, but it is not always easy to implement beyond a project-by-project approach.
Generally, evidence-based practice is described as the integration of clinical expertise and opinion acquired through one’s training and experience; evidence gathered from scientific literature and from data about the patient; and the patient or caregiver perspectives regarding values, priorities, and expectations.
Evidence-based practice can improve quality of care, lower costs, and prompt better patient outcomes. However, inadequate knowledge and skills, along with a lack of leadership support, can hamper attempts to fully embrace evidence-based practice. Competing organizational priorities and limited funding also can prove challenging.
The deployment of evidence-based practice in healthcare minimizes unnecessary variation in practice, says Kim Pardini-Kiely, director in the clinical and operational excellence and innovation services practice with the consulting firm Protiviti in San Francisco. Evidence-based practices are based on published scientific evidence and are used in medicine, nursing, and other clinical services, she notes. Such practices guide clinical decision-making, which results in better patient outcomes.
“Evidence-based practice can take many shapes, from standard order sets to clinical protocols for treatment of disease and medical conditions. For example, a standard order set for a surgical procedure can direct the most appropriate use of preventive medications, such as antibiotics,” Pardini-Kiely says. “An example of a clinical protocol is for the administration of blood and blood products, which would set when to administer blood products by setting indications for transfusions.”
Evidence-based practice is best implemented by consensus and developed by bedside clinicians using the evidence-based research, she says. A broad representative group should be convened and guided by the use of common improvement methods such as lean healthcare or design thinking. Evidence-based practice should be approved and supported by oversight bodies such as the medical executive committee or nursing practice councils.
“The biggest challenge is breaking down long-held beliefs about how best to manage patient care and getting the team to embrace newer, more compelling evidence. Overcoming these challenges is best managed by developing a deep understanding of current beliefs and practices, and then working together to design an approach that focuses on better outcomes,” Pardini-Kiely says. “Changing practices is hard because it often includes a change in beliefs and behaviors. Giving clinicians an opportunity to understand why the change is necessary and to be a part of designing new practices is essential to achiev[ing] success.”
The most common mistake made with implementing evidence-based practice is taking a top-down approach, Pardini-Kiely says. Just publishing evidence-based practice in an organization and telling clinicians to use them is ineffective, she cautions. Leaders from medical staff, nursing staff, and administration need to engage not only clinicians but also the distribution of the evidence-based practice, she says, paying particular attention to the workflow that supports the ease of use of guidelines.
Hospital Revises Processes
Rady Children’s Hospital-San Diego used evidence-based practice to develop a process that aligned organizational culture, underlying infrastructure, and staff training. Other institutions can use the same method to develop practices and documents based on the best evidence to support patient outcomes, says Suzan R. Miller-Hoover, DNP, RN, CCNS, a nurse scientist and owner of SRMH Consulting in Pine, AZ. She worked with Rady on the evidence-based practice project.
Working with other hospitals, the evidence-based practice team at Rady identified challenges related to infrastructure, including fragmented resources, inconsistent guidance, and lack of organization. They determined clinical units operated under their own standards of care, and that policies and procedures often varied among units.
The team developed a standard of nursing care for all patients and standardized documentation. They also consolidated standing orders and standardized procedures. The group eliminated duplications and inconsistencies, reducing variations in care for staff who floated among different units. (More information on Rady’s experience is available here.)
Miller-Hoover is a clinical nurse specialist who focused much of her education on evidence-based practice. She describes evidence-based practice as taking research data and putting it to work in a hospital in combination with a nurse’s experience and the particulars of the patient population. Combining those elements into the most effective way to provide patient care is at the heart of evidence-based practice, she explains.
“It’s important that everything we do in nursing and physician care has been researched, but that often is not enough for getting the most impact from that research,” Miller-Hoover says. “You have to bring that research into your organization, find all the right players, and develop a way to incorporate that research with what your people know and what you know about your patient population.”
Clinicians May Resist
Some of the common challenges with implementing evidence-based practice involve clinicians who are not sure what this approach entails, beyond what they know generally as good medical and nursing skills, Miller-Hoover says. It is important to educate them on evidence-based practice and gain their trust when trying to fully implement evidence-based practice.
In the case of Rady Children’s Hospital, that effort was aided by the fact the hospital was participating in a nine-month program involving a consortium of medical facilities in the San Diego area. Participants focused on learning how to read research and ascertain its value, and how to apply the findings to their own organizations.
A hospital seeking to fully and effectively embrace evidence-based practice needs a champion who is enthusiastic about the initiative, Miller-Hoover says. This person does not necessarily have to be a top executive, but this champion needs to be able to work with senior administration and clinicians.
The Rady team also worked closely with the quality director to be sure the evidence-based practice team was complying with all applicable quality directives and compliance requirements.
“The most important lesson I took away from the experience was that administration absolutely has to be on board because evidence-based practice is not inexpensive,” Miller-Hoover says. “For example, the group of clinical nurse specialists and I had to meet weekly for a year just to hash out the policies and procedures and standardize things. Without the administration’s approval, our directors probably never would have had been able to let the nurses out of the units they worked on.”
As the team moved forward with changing standards of care and creating uniform practices, Miller-Hoover says it was essential the administration knew what they were doing and were supportive.
“Everyone should make an effort to implement evidence-based practice. Study the research, find out the why behind it, then look at your nurses’ experience to see if it is something that will fit,” Miller-Hoover says. “That’s what evidence-based practice is all about, taking what is known to work and generalizing it down to your population. Not all patients are the same. You may have to tweak it to your nurses’ experience and your patient preferences.”
Evidence-based practice is one way healthcare organizations and individual clinicians can manage the wealth of information on which they are expected to stay current and apply to their patient care, says Robert Dean, DO, MBA, a cardiac anesthesiologist and senior vice president in performance management with Vizient, in Holland, MI.
“Particularly now with COVID-19, there is so much evidence coming out, and it’s changing all the time. What we knew three months ago doesn’t seem relevant in some ways,” Dean says. “We’re always looking for the best way to do something from a clinical standpoint. It can be hard to know what to do with data. [The data] seem legitimate, but might not be a complete match with what you know of your own patients and what your own experience tells you.”
Evidence-based practice addresses the fluidity of medicine and the changing outlooks on what physicians, nurses, and other clinicians originally learned, Dean says.
“Many of us are trained to do certain things in our resident or our postgraduate training. While it is current at the time, many clinicians stick to that training even when they are years out into practice,” Dean says. “That makes using evidence-based practice challenging sometimes. I’ve had partners who say, ‘This is the way I’ve trained, and this is the way I’m doing it.’ It’s really incumbent on other clinicians to help pull together the current information on a regular basis in order to say, ‘Yes, we trained this way to treat perioperative hypertension. Now, the evidence shows that there is a better way to reduce patient mortality and morbidity, improve compliance, and have better long-term results.’”
To make any impact on reluctant clinicians, the people pulling together that data and urging new pathways need to be fellow clinicians, Dean says. These are not just clinician leaders, but also physicians and nurses who are respected in the organization for how they stay updated on current best practices.
“That’s a key there, having not just an outside voice that says this is the best evidence but using people within your organization who have that day-to-day credibility,” Dean says.
Hospitals should make the data available for review and also make time in clinicians’ schedules for them to discuss the research and how it might be applied to a care pathway, Dean offers.
When working with the Transformation of Clinical Practice Initiative with the Centers for Medicare & Medicaid Services (CMS), which helped clinicians move from a fee-for-service environment to a value-based environment, Dean and his colleagues monitored four criteria: hemoglobin, hypertension control, smoking cessation counseling, and depression screening.
After collecting data for a year, Dean’s team saw no real improvement in the numbers, even though they were emphasizing how to use evidence-based care with those practices. Dean and colleagues asked the practice organization leaders why the effort was not successful.
“They said it was because we really don’t have performance improvement capabilities in our practice organizations. We haven’t made time during the week or the month to regularly review our data, look at what the evidence is and how we are complying with that,” Dean explains. “There is a structure and process component to implementing evidence-based care that isn’t always there. If people don’t make time for it, it really never is fully or successfully implemented.”
More Important Than Ever
Evidence-based practice applies across the board to all clinical specialties and settings, Dean says. It has become more important recently because so many people have avoided routine care for chronic disease or new disease onset because of the COVID-19 pandemic, he observes. It will be more important than ever to use evidence-based practice to optimize the care of these patients who may have lost progress in their disease management or who have become more seriously ill before receiving treatment.
“I think evidence-based care has never been more important than it is right now,” Dean says. “Those organizations that have value-based payments, in an ACO [accountable care organization] or in a shared saving program where their payment is based on how well they manage these patients, really require the use of evidence-based practice. I think we’re going to see a shift in the next few years of more organizations moving toward that value-based payment. To do well there, they are going to have to adopt evidence-based practice.”
In addition to its adoption throughout an organization, individual physicians, nurses, and other clinicians can pursue evidence-based practice, Dean notes. Clinicians tend to be lifelong learners, and many must stay abreast of current research to meet state licensing requirements.
“There are performance measurements. Most organizations, through their quality departments, are using process measurement to look at things like how often you use ACE inhibitors for heart failure,” he says. “Everyone is being measured these days, by payers and organizations you’re affiliated with, and CMS — even consumer ratings, in a way that didn’t exist 10 years ago. It is important for physicians and others stay up to date because others are monitoring and measuring their performance. Evidence-based practice is the best way to provide excellent care.”
Care Practices Not Uniform
Healthcare interventions based on evidence are the gold standard for high-quality patient care, according to Charles Tuchinda, MD, MBA, president of Zynx Health, a company based in Los Angeles that assists healthcare organizations with evidence-based quality improvement.
“The unfortunate truth is that we haven’t quite gotten to a state of practice where people routinely deliver all the correct evidence-based interventions to every patient,” Tuchinda says. “We see variations in clinical practice from what we define as best. The goal for anyone in quality improvement should be to increase the use of those evidence-based interventions, and that will lead to more effective care, with a lower risk of complications.”
Evidence-based practice is about more than just keeping up with the latest research, Tuchinda notes. Medical studies are reported at such a rate that the typical clinician cannot keep up with all the latest findings in their own fields, much less research from other fields that still may be applicable to care decisions, he says.
Some research also requires a public health or epidemiological background that most clinicians do not have, he notes. For those reasons, a formal evidence-based practice approach is necessary. The hospital or other healthcare organization provides insight into the latest research, and then assists clinicians with understanding how it applies to them and their patients.
All areas of healthcare are adopting evidence-based practice, Tuchinda notes.
“It is the standard of care now. Evidence-based practice is the norm. Frankly, if you have variations from it, you are creating liabilities for yourself and the institution,” he says. “When you think about how you actually put it into practice and drive those quality measures, you have to think about what are the key interventions that you have to do to make sure the patient gets on the right track. The body of information out there is overwhelming, but you have to find the key nuggets, the things that, even if you forget everything else, are going to drive your mortality, your morbidity, the lengths of stay.”
Play on Competitiveness
Even that is not enough if physicians are reluctant to follow the information provided. Tuchinda notes that physicians tend to be competitive and will respond well when presented with a comparison of their performance against their peers.
“Physicians hate it when you tell them they are performing poorly or they are in the bottom 25%. That was a big motivator for me to receive a report like that. I was highly motivated to find out what I could do differently,” he says. “Once you give people the knowledge and tools, you still have to drive them to make the change. There was a time when people thought that if you just put it in the process, then things will get better. But we’ve seen that variances still occur. That speaks to the fact that there is a human part of this.”
The transition to value-based care has spurred evidence-based practice by incentivizing healthcare organizations to produce the best data on patient care, notes Dana Bensinger, MSN, RN-BC, an informatics nurse specialist and client solutions executive with Computer Task Group in Buffalo, NY. With outcomes dramatically affecting the bottom line, hospitals and clinicians have become more open to hearing what others are doing and which practices have been most successful, he says.
“The key elements in evidence-based practice is the evidence itself, the clinician’s judgment, and the patient population. Being able to understand what others are doing and what applies to your patient and your practice is key,” Bensinger says. “In the past, people were more comfortable saying they knew best and saw no reason to change. Value-based care has pushed them to be more open about what others are doing and what they might adopt.”
Bensinger says the COVID-19 experience may prompt healthcare organizations to make evidence-based practice more agile. The rapidly evolving, and often conflicting, research on the coronavirus prompted some concerns that evidence-based practice could not adapt as rapidly as needed, he says.
“I think we’re going to see more agility, an effort to get evidence-based guidelines out faster than we have before,” Bensinger says.
SOURCES
- Dana Bensinger, MSN, RN-BC, Informatics Nurse Specialist, Client Solutions Executive, Computer Task Group, Buffalo, NY. Phone: (716) 882-8000.
- Robert Dean, Senior Vice President, Performance Management, Vizient, Holland, MI. Email: [email protected].
- Suzan R. Miller-Hoover, DNP, RN, CCNS, SRMH Consulting, Pine, AZ. Email: [email protected].
- Kim Pardini-Kiely, Director, Clinical & Operational Excellence and Innovation Services, Protiviti, San Francisco. Phone: (415) 402-3600.
- Charles Tuchinda, MD, MBA, President, Zynx Health, Los Angeles. Phone: (310) 954-1950.
Evidence-based practice is a proven approach for hospitals as well as individual physicians and nurses, but it is not always easy to implement beyond a project-by-project approach.
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