What is entailed in Planning for Sustainable Change?

Following the Evidence: Planning for Sustainable Change The EBP team makes plans to implement an RRT in their hospital.

This is the eighth article in a series from the Arizona State University College of Nursing and Health Innovation’s Cen- ter for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational cul- ture, the highest quality of care and best patient outcomes can be achieved. What is entailed in Planning for Sustainable Change?

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The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every other month to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we’ve scheduled “Chat with the Authors” calls every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the next call will be published with May’s Evidence-Based Practice, Step by Step.


After the evidence-based practice (EBP) team of Rebecca R., Carlos A., and Chen M. synthesized and appraised the evidence they found to answer their clinical question, they concluded that rapid re- sponse teams (RRTs) were effec- tive in reducing both code rates outside the ICU (CRO) and non- ICU mortality (NIM), excluding patients with do not resuscitate (DNR) orders (see “Clinical Ap- praisal of the Evidence: Part III,” November 2010). They also de- cided that a reduction in un- planned ICU admissions (UICUA) may be a reasonable outcome to expect. In addition, they chose the members of their RRT: an advanced practice nurse, a phy- sician, an ICU staff nurse, a respi- ratory therapist, and a chaplain.

The team’s next step is to de- velop a plan to implement an RRT in their hospital. They be gin by planning how to collect baseline data on their chosen outcomes so they can evaluate the RRT’s impact on those outcomes. Carlos explains to the team that measuring out- comes, typically before and after implementing an intervention, is

essential to documenting the im- pact of the EBP implementation project on health care quality and/ or patient outcomes.1 Rebecca adds that they’ll also need to con- sider cost as an outcome and must plan for how to capture the costs of the RRT as well as evaluate the cost savings for positive changes in CRO, NIM, and UICUA.

THE IMPLEMENTATION PLAN Rebecca and Chen are excited about the plan to implement an RRT in their hospital and tell Carlos how much they appreci- ate his ongoing support. Carlos checks in often with the team now that the project is under way. His experience as an expert EBP mentor has taught him the importance of assessing the team’s progress at frequent intervals to see how he can support them.

To help the team develop a detailed plan for implementing an RRT in their hospital, Car- los pro vides them with an EBP Implementation Plan template that he used in his EBP Gradu – ate Certificate Program (Figure 1). This plan was developed using the Advancing Research and Clinical Practice Through Close Collaboration (ARCC) model, in which EBP mentors are key fa cilitators of sustainable change. Carlos explains that even though they now have a template to guide them in the process, EBP implementation can be unpre- dictable. The team cannot antic- ipate all of the challenges or or- ganizational nuances they may encounter in launching an RRT in their hospital.

Preliminary checkpoint catch- up. The team reviews the template, beginning with the Preliminary Checkpoint, to determine which steps they’ve already taken and which they’ll need to prepare for going forward. They’ve al- ready completed checkpoints one through four, but two steps in the preliminary checkpoint still need to be addressed: identifying key stake- holders and acquiring approval from the internal review board (IRB; sometimes called the ethics review board, or the human sub- jects or ethics committee). The team members discuss their roles in the project and agree that these may evolve as the implementation plan develops. What is entailed in Planning for Sustainable Change?

Key stakeholders. Carlos tells Rebecca and Chen that consider- ing who would be stakeholders in a project—in this case, those individuals or groups that may be affected by or can influence the implementation of an RRT—is a step that’s often overlooked. He explains that active stakeholders are those people who have a key role in making the project happen. Passive stakeholders are those who may not be actively involved in the project but who could promote or stymie its success. Carlos ad- vises the team to consider all po- tential stakeholders, as theirs is an organization-wide project and some stakeholders may not be ob- vious. He asks Rebecca and Chen to think about the outcomes of the project and to which stake- holders throughout the hospital they’d be important. The team discusses that, as staff nurses, they don’t always think about their work from an organizational standpoint. Carlos says that thinking about the project in an organization-wide context will help them figure out who needs to be on the team. He provides examples of stakeholders who would not only be critical to the RRT process but who might also have connections that could be important to the project’s success. For example, connecting with key councils (practice, quality, criti cal care) or work groups (education, communications) may provide ac – cess to already- established pro- cesses for introduc ing a policy into the organization.

The team preliminarily identifies the members of their RRT, patients, staff nurses, and administrators as active stakeholders. They identify the finance, risk management, and education departments, mid- level managers, and the chief ex- ecutive and chief nursing officers as potential passive stakeholders.

The team agrees that although these may not be all of the stake- holders—more may be identified as planning continues—they’re likely key players who need to be included in the implementation plan for now. Carlos tells the team that it’s important to keep thinking about who will impact the project and whom the project will impact, so that everyone who needs to be on board with the plan is brought on early.

IRB approval. Carlos explains that an IRB is charged with mak- ing sure that subjects involved in a research study are safe and that the research is conducted in such a way that the findings are applicable to a broader popula- tion than just those in the study, which is known as generalizabil­ ity.2 The team discusses whether they need to submit their imple- men tation plan to their hospital’s IRB for approval, since they’re not conducting research. Al- though they’ll be collecting out- comes data to evaluate whether they’re achiev ing the expected outcomes cited in the literature, their evidence-based RRT inter- vention is a best practice improve- ment project, not a research study. Still, Car los stresses that the team has an obligation to publish how their evidence-based intervention works in their hospital. He re minds them that the seventh step in the EBP process is to disseminate re- sults so others can learn how a project was implemented and eval – uated (the process) and whether the out comes identified in the lit- erature were obtained (the pro­ ject outcomes, or end points) (see “The Seven Steps of Evidence- Based Practice,” January 2010). Car los tells Rebecca and Chen that if they’re going to publish their pro ject, they’ll need to submit their implementation plan for IRB approval. Moreover, theycannot collect their baseline data without prior IRB approval. The team dis cusses that when they write up their project, they can address some of the issues they had with the reporting of implementa- tion projects in the literature, such as how differences in the format- ting of these reports makes it hard to synthesize the data (see “Clini- cal Appraisal of the Evidence: Part III,” November 2010). For these reasons, the team feels it’s essen- tial that they publish their project, so they’ll pursue IRB approval.

Before the team begins writ- ing up their implementation plan (which they will reformulate as an IRB proposal), they discuss an essential assumption they hold, which is that all patients who enter a hospital sign a “consent for treatment” expecting clinicians and others caring for them to pro- vide the best care possible. Al- though patients may not re fer to their care as evidence­based prac­ tice, the EBP team feels strongly that patients’ expectations reflect professional practice in which daily decisions are made based on the best evidence available. With this expectation and their decision to publish the project in mind, the team discusses that the outcomes data will be used in a way that wasn’t covered in the consent for treatment. Thus, the IRB review of their proposal should reveal any ways in which publishing the outcomes of the project could put recipients of the practice change at risk. In effect, the IRB would be reviewing the plan to make sure that the data from those patients. What is entailed in Planning for Sustainable Change?