Posts Tagged ‘evidence-based medicine’

Guest Post: Outcomes Drive the Evidence-Based Practice Journey

March 29th, 2018 by Michele Farrington and Cindy Dawson

The Institute of Medicine set a goal that 90 percent of all healthcare decisions will be evidence-based by 2020. Executives and nursing leaders, at all levels within organizations, have clear responsibility for making this goal a reality and ensuring consistent, standardized use of evidence-based practice (EBP) in care delivery that will meet patient, family, clinician, and organizational outcomes.

Promoting use of evidence, valuing questioning of clinical and administrative practice, and building organizational capacity, culture, and commitment are pivotal to building a supportive organizational culture related to EBP.

Organizations must meet regulatory requirements, from the Centers for Medicare and Medicaid Services and The Joint Commission, that incorporate EBPs and the need for increasing public accountability and transparency (e.g., use of national benchmarks) for quality and safety. Financial incentives associated with pay-for-performance are also directly linked to EBP. Despite these outside forces in today’s healthcare environment, clinicians and executives cannot forget about the need to provide individualized patient care, which includes patient engagement strategies aimed at improving the overall patient experience.

EBP is a continuous journey for individual clinicians and organizations alike and starts with building organizational capacity.

Organizational Capacity

EBP capacity is built using a strategic, systematic approach to create a solid foundation and infrastructure to support the work. Before EBP work can be successful at the unit or clinic level, EBP must be integrated at the organizational level and a culture for change must exist.

The organization’s mission, vision, and strategic plan must include EBP language to ensure evidence-based healthcare is clearly portrayed as the organizational norm. Creating a culture valuing inquiry and innovation must start during orientation for new hires and continue during competency review for current employees and through ongoing training and professional development opportunities for both clinicians and executive leaders.

An infrastructure that directly integrates EBP work into the organizational governance structure is needed to support the mission, vision, and strategic plan. A crucial organizational decision is determining what group will hold primary accountability or functional responsibility for EBP to ensure it is integrated into practice processes, policies, and documentation.

Recruiting and hiring clinicians and executives with experience and/or interest in EBP will help build the desired culture and capacity. EBP mentors are developed from successful projects and are used to nurture the next generation.

A well-defined path for EBP includes adoption of an EBP-process model to guide implementation and sustained organizational change across disciplines. There are a number of EBP process models: The Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care; Johns Hopkins Nursing Evidence-Based Practice Model; Stetler Model of Evidence-Based Practice; and Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model. Each model follows a step-by-step problem-solving process suitable for concurrent use with the organization’s quality improvement processes.

Culture

The governance structure must clearly outline the process and channels for communicating EBP work and obtaining necessary approvals from applicable committees. EBP discussions should be a regular agenda item for all shared governance committees.

Project results should be reported internally through the organization’s shared governance and quality improvement structures to promote practice change adoption, share learning, garner continued support (e.g., time, resources), and as a platform to recognize success for the institution’s EBP program.

Successful EBP work takes time and effort, so successes should be celebrated and rewarded throughout the process. Celebrations are an opportunity to spotlight clinicians for doing this work and helps build a pervasive culture that supports and expects use of evidence in practice. These strategies promote organizational buy-in and commitment for the EBP process and set higher standards as a foundation for future efforts.

Expected behaviors from clinicians across all job classifications at every level must clearly demonstrate the value of EBP. Behavioral expectations regarding EBP are easily set if they are built into every job description and can be quickly reviewed annually during the performance appraisal process. Utilizing documents and mechanisms that already occur is an easy and efficient way to promote positive reinforcement and priority setting in busy work environments with many ongoing and competing demands for clinicians’ and leaders’ time and attention.

Benefits

EBP is value-added with a strong return on investment and responds to current priorities. A single project may improve patient and clinician safety, improve clinical outcomes, improve patient/family satisfaction, promote innovate care, and/or reduce costs.

Clinicians, nurses, and leaders all influence an organization’s capacity for EBP. Leaders who demonstrate and expect EBP will promote its use in clinical and operational decision-making at the unit or clinic and organizational levels. Building on the organization’s mission, vision, capacity, and value for delivery of reliable, safe, high quality care provides a foundation for success.

About the Authors:

Michele Farrington, BSN, RN, CPHON, is a clinical healthcare research associate at the University of Iowa Hospitals and Clinics. She is certified in pediatric hematology/oncology nursing and received her BSN from the University of Iowa. She has been leading, co-leading, or mentoring EBP initiatives since 2003, and her work has been awarded extramural funding, validating the strength of the projects and impact on nursing care. She is widely published and has given multiple local, regional, national, and international presentations.

Cindy Dawson, MSN, RN, CORLN, is the chief nurse executive and associate director of the University of Iowa Hospitals and Clinics. She received her BSN from the University of Iowa, MSN from the University of Phoenix, and is a Certified Otorhinolaryngology Nurse. Over the course of her career, she has published extensively on EBP, nurse triage, nursing management/leadership, and clinical practice guidelines and has given numerous local, regional, national, and international presentations on these topics.

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Infographic: Evidence-based Guidelines for Managing Low-Back Pain

February 15th, 2017 by Melanie Matthews

Evidence-based Guidelines for Managing Low-Back Pain

The complexity and intensity of treatment for lower back pain may vary depending on how likely it is that the patient will have a good, functional outcome, according to a new infographic by BMJ Publishing Group.

The infographic provide care pathways for patients by expected outcome.

When success in a fee-for-value reimbursement framework calls for a care coordination vision focused on the highest-risk, highest-cost patients, an organization must be able to identify this critical population.

2016 Healthcare Benchmarks: Stratifying High-Risk Patients captures the latest tools and practices employed by healthcare organizations across the care continuum as they risk-stratify patients and health plan members in preparation for care management.

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Infographic: Physician Practice Patterns

August 27th, 2014 by Melanie Matthews

Physicians are key to improving hospital quality and lowering costs, according to a new infographic by Dimensional Insight.

The infographic looks at how physicians influence healthcare spending, the growing trend toward physician data transparency and the potential impact if all states improved to best-performing state levels.

Physician Practice Patterns

Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for PerformanceIn healthcare’s post-reform volume-to-value world, payor reimbursement strategies are tipping in favor of providers who can deliver the clinical and financial goods. In the mix are bundled payments, shared savings, pay for performance and bonuses — with some going so far as to restructure organizations for maximum gain. The Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for Performance goes beyond theory explores emerging models of episode-based payments, physician-hospital organizations and physician bonus structures.

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Self-Examination: Industry Questioning Necessity, Cost Irregularities of Healthcare Services

May 2nd, 2012 by Cheryl Miller

Regardless of whether the Supreme Court overhauls health reform, the industry is seriously thinking about ways to cut healthcare spending, either by reexamining the need for commonly administered services or unraveling the mysteries of medical bills.

As we reported in a recent news story here, a coalition of nine leading physician specialty societies representing nearly 375,000 physicians have identified specific tests or procedures that they say are commonly used but not always necessary in their respective fields.

Coordinated by ABIM Foundation’s Choosing Wisely campaign, the lists of “Five Things Physicians and Patients Should Question” provide specific, evidence-based recommendations physicians and patients should discuss when making healthcare decisions. Among the tests that patients might not necessarily need are stress imaging tests for annual checkups if the patient is an otherwise healthy adult without cardiac symptoms, according to the American College of Cardiology, and chest X-rays for patients going into outpatient surgery, according to the American College of Radiology. Most of the time, the x-ray images will not result in a change in management and have not been shown to improve patient outcomes, college officials say.

A recent opinion piece from the New York Times echoes the feeling that more evaluation of health services and costs is necessary, and sheds some light on the abundance of medical tests. The article, Why Medical Bills are a Mystery, written by Robert S. Kaplan and Michael E. Porter, professors of accounting and strategy, respectively, at Harvard Business School, states that:

The lack of cost and outcome information also prevents the forces of competition from working: Hospitals and doctors are reimbursed for performing lots of procedures and tests regardless of whether they are necessary to make their patients get better. Providers who excel and achieve better outcomes with fewer visits, procedures and complications are penalized by being paid less.

The article goes on to cite a lack of uniformity for healthcare costs and reimbursements, and suggests that by analyzing costs, hospitals can save money and improve care:

Because health care charges and reimbursements have become disconnected from actual costs, some procedures are reimbursed very generously, while others are priced below their actual cost or not reimbursed at all. This leads many providers to expand into well-reimbursed procedures, like knee and hip replacements or high-end imaging, producing huge excess capacity for these at the same time that shortages persist in poorly reimbursed but critical services like primary and preventive care.

A new University of California San Francisco (UCSF) study published online this week in Archives of Internal Medicine underscores the concerns voiced by Kaplan and Porter:

The study looked at nearly 20,000 cases of routine appendicitis at 289 hospitals and medical centers throughout California. The patients – all adults – were admitted for three or fewer days. The researchers uncovered an enormous discrepancy in what different hospitals charge, ranging from a low of $1,529 to a high of nearly $183,000. The median hospital charge was $33,611. The startling cost variation reveals a “broken system,” the authors said.

“Consumers should have a reasonable idea of how much their medical care will cost, but both they and their healthcare providers are often unaware of the costs,” said lead author Renee Y. Hsia, MD, an assistant professor of emergency medicine at UCSF.

What to do? The Journal of the American Medical Association (JAMA) weighed in on ways to cut waste and improve quality in U.S. healthcare. In a recent article researchers identified six categories where cuts could result in a significant reduction in healthcare costs. In these six categories: overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse, the sum of the lowest available estimates exceed 20 percent of total healthcare expenditures.