EVIDENCE IS KEY IN BOTH HIGH-RELIABILITY ORGANIZATIONS AND EVIDENCE-BASED PRACTICE CULTURES
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Careful tracking of data along with outcomes monitoring of key system and patient outcomes is critical in an HRHO. Furthermore, external evidence from both rigorous research and internal evidence (ie, data that are generated from practice, pa- tients, and outcomes management) is criti- cal to formulating the best practices to im- prove the quality and safety of care. In an HRHO and an EBP culture, leaders engage in evidence-based management and clinicians engage in EBP. Evidence-based practice is a problem-solving approach to the delivery of care that integrates the best evidence from well-designed studies with a clinician’s ex- pertise, including clinical wisdom, reasoning, patient history, physical data collection and resource utilization, and a patient’s prefer- ences and values to make decisions about the type of care provided.22 The ultimate pur- pose of EBP is to improve health care qual- ity and patient outcomes and reduce hospital costs. When evidence-based care is delivered within an EBP culture and a context of car- ing, the best patient outcomes are achieved (Figure 1).
THE STEPS OF EVIDENCE-BASED PRACTICE
To build HRHOs and EBP cultures, clini- cians should learn and consistently implement the steps of EBP, which include (1) cultivate a spirit of inquiry; (2) ask clinical questions in PICOT format, which stands for patient pop- ulation of interest, intervention of interest,
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The ARCC Model for Systemwide Sustainability of EBP 131
Clinical decision making
Quality patient outcomes
Research evidence and evidence-based
theories
Clinical expertise (eg, evidence from patient assessment, internal
evidence, and the use of health care resources)
Patient preferences
Context of caring
EBP organizational culture
Figure 1. The evidence-based practice (EBP) paradigm. Copyright 2003 Melnyk and Fineout-Overholt.
Comparison intervention or group, outcome, and time (eg, In intubated patients in the ICU (P), how does early ambulation (I) vs delayed ambulation (C) affect episodes of ventilator- associated pneumonia (O) while in the ICU (T)?);
(3) search for the best evidence;
(4) in- tegrate the evidence with clinical expertise and patient preferences to make the best clin- ical decision;
(5) evaluate the outcome(s) of the EBP change; and
(6) disseminate the out- comes so that other patients can benefit.
In EBP, if there is enough high-quality evidence from research to change practice, the prac- tice is changed and outcomes are monitored to support that the change in practice based on research produces positive outcomes in the real-world setting. If there is not enough high-quality evidence to change practice, ex- ternal evidence must be generated through rigorous research or internal evidence pro- duced through quality improvement or out- comes management projects. High-reliability health care organizations begin with leaders and point-of-care providers who take the time to think and reflect about the care that is be- ing delivered and continually ask how it can be improved, which is analogous to cultivat- ing a spirit of inquiry or step 0 in the EBP process.