Welcome to the module two of the course Take the Lead in
Healthcare Quality Improvement.
This module will focus on the evidence, specifically looking at what is
the evidence in the literature and what evidence exists in the industry in
relationship to the problem that you're interested in exploring.
Remember, in quality improvement, you're doing your work and
you're improving your work at the same time.
And as you recall in module one, we were looking at the quality improvement gap,
the difference between what we know and then what we do.
Some examples of that are, is if you were a physician and you're working in
a patient centered medical home and you look at your panel of patients and
you realize that only 50% of your patients are taking aspirin.
And you know that quite a few of those patients are diabetics.
Or patients with a history of heart disease, and you realize that
they probably need to be on the aspirin because it is evidence based.
With this knowledge and this gap, then you go forward on your quality
improvement process, and that's what we're going to learn more about today.
Another example is if you're a nurse, and you realize from your management,
that the deep vein thrombosis incidence is high on your unit,
higher than the national average, and your manager tells you that the floor and
the unit need to do something about this.
You know exactly what you should be doing as a nurse, regarding prevention of
deep vein thrombosis, and you realize that there's a gap in care.
That what you know and what you do, is not consistent.
This module will cover chapter two of the book:
Finding Scientific Evidence to Apply for Clinical Improvement.
Here the objectives of this chapter are to look at the link between evidence, and
context of care.
And then really to learn about how to ask the right questions.
And the third objective is to understand the difference between filtered and
unfiltered evidence.
What is evidence based practice?
It's a process of shared decision making between the practitioner or
healthcare worker and the patients.
This shared decision is based on research evidence, patient's experience and
preferences, clinical expertise and
then, other available robust sources of information.
For evidence based practice, there's really no source of
evidence that's considered more important than any other source.
And applying the best known evidence, using clinical judgment is really the key.
For evidence based practice, we take patient's preferences and
their experiences, and their values.
And we add that with our own research and other sources of evidence,
in order to provide good care decisions for our patients.
Evidence based practice provides a solid foundation for
asking the right questions and finding answers.
However, it is limited as it does not link evidence to the systems of
care in which you work.
Finding the right evidence and
applying that evidence in practice are two separate steps.
And we may recall in chapter one this model, where it's the evidence based
improvement equation, where we take generalizable scientific evidence and
then we add our particular context.
What's going on in the unit we work or in the institution that we practice care.
And this is the key then for evidence based practice.
Not only the scientific evidence but
also our particular context that leads to improved measured performance.
So asking the right questions is a key.
For this, we want to distinguish between background questions and
foreground questions.
With background questions, it's going to give us information and
evidence in general information regarding your problem.
So for example, what's the percentage of patients who
acquire a deep vein thrombosis during their hospitalization?
Or, how do we prevent deep vein thrombosis?
What's the background on the problem we're interested in?
In contrast, foreground questions are contextual.
Here our foreground questions are specific populations that
we're interested in studying.
What are interventions that we find in the literature in the evidence that
demonstrate better outcomes?
What are the comparisons between interventions that are available in
the literature and really the outcomes that we really need to be looking at.
This is the model that's in chapter two and I'd like for
you to look at it in a little bit of detail.
This is a model to help you to really evaluate the strength of the evidence.
And also to look at deciphering concepts of unfiltered evidence and
then filtered evidence.
So, if you look at the foundation of this model, you'll see that the bottom or
foundation of the model is background information and expert opinion.
As you raise up the pyramid,
you'll see that the next level of evidence are case controlled studies or
case reports that you find in the literature when you do your search.
The third level is Cohort studies that could be retrospective or prospective.
The next tier in the pyramid are randomized controlled trials or RCTs.
Now note to the right, that these are then described as unfiltered information.
These are original works.
Original pieces of evidence to demonstrate what is working in healthcare.
As we raise up the pyramid, we see that the next level is
critically appraised individual articles, or article synopses.
Where someone, the author of this article, examines many research articles or
many cohort studies or case controlled studies and then comes to a conclusion.
Next are critically appraised topics such as evidence synopsis.
And the last are systematic reviews.
And as you can see on the left of the pyramid that the quality and
strength of the evidence rises as you rise up the pyramid.
The pyramid also identifies distinguishing concepts of unfiltered information and
then filtered information.
I'd like to first go over unfiltered information, and
these are examples of an expert opinion or case studies or case controlled studies.
Cohort studies, randomized control trials, where there's one
author who is disseminating this evidence in the literature.
In comparison to filtered information, where the literature is taken or
the specific research articles are found in the literature and
then they're summarized or put in a summary statement.
Such as appraising the evidence and then offering recommendations for practice.
Summaries can be also seen as evidence based syntheses or systematic reviews.
And many clinical practice guidelines then do depend on these syntheses in order to
make recommendations for care.
So choosing the right resource based on a question is a critical part of your
evidence based literature search.
And if you go on page 25 in the book,
you can see that there is a resource table that is very helpful.
And I'd like for you to go back to this after this lecture,
to look at the table in a little bit more detail.
I'd like to now go over an example of that.
The table has on it headers that include question,
then examples of questions that could be asked in order to
find more evidence in literature, and then the resources that you
can consider looking at in order to answer those questions.
An example of that is the topic of synthesis of best practice
recommendations for disease management. And if you look at the table under this row,
it then lists some resources that are available for
you to use in order to find evidence for examining your problem.
The first is the Cochrane database.
Another resource that can be used is Medline.
A third is the National Guideline Clearinghouse.
And then a fourth resource that they recommend is the TRIP Database.
This table in chapter two, will be essential for you,
in order to identify resources to use to find the evidence that you will need for
background and foreground information for your problem.
Also, the book chapter identifies levels of searches.
There are three levels that they identify.
The first level are rapid searches where you are very interested in
a topic you go to Google, you put in a question,
and the Google comes up with some responses.
The next level would be careful searches, where you're planning the strategy,
where you consciously plan out where you'll first start your search,
such as CINAHL or PubMed and then extend your plan then to
other types of strategies such as going to professional organization websites.
And then the third level of search is really going to the expert.
A reference librarian would be essential in this level of search or a hospital
personnel who also is an expert in finding citations and references for you.
I'd like to also pause here for
an additional search that isn't really identified in the literature but is
very important in your evidence for your project in which you are embarking on.
And that is doing an industry assessment.
An industry assessment is a part where you're looking at what other
hospitals are doing or what other evidence there is in the web or
the Internet to determine some ideas for
what could be some strategies that you could use for your improvement.
The questions you would ask on an industry assessment are,
well, what are some other institutions doing?
How you can get this information?
Well, you can Google,
you can go to some resources on the Internet,
or you could call up other institutions
and say that this is a problem that you're investigating
and you'd like to find out some tips or
techniques that they're engaging in, in order to improve their outcomes.
A second question you could ask for
an industry assessment is, what is recommended by the Institute for
Healthcare Improvement or the Agency for Healthcare Research and Quality?
The IHI and the AHRQ are great references to use on the Internet to determine
what the industry is recommending for your specific problem in order for
you to improve the quality of care you're delivering.
I'd like to go back then now to our case study from module one, and Dr.
Wes Self, he produced this PowerPoint presentation about the quality improvement
program to reduce blood culture contamination in the emergency department.
And I'd like to review the case study just to demonstrate in his case study,
which are examples of background information and
which are some examples of foreground information.
We can also think about what would be filtered, and
what would be non-filtered information.
So, in his PowerPoint presentation he does talk about some references and
evidence about blood cultures in general and contamination.
This would be considered background evidence.
He also talks about the potential contaminants and
in this literature search he also is identifying some background evidence.
This is a third example of background evidence that he's providing in
order to set up his story board for his improvement project so
that we can all understand some background information about the problem at hand,
and also, to emphasize the significance of this improvement effort,
and what might be some outcomes then of and results of his improvement project.
Another background evidence slide.
This is also highlighting that there is a lot of background information that is
needed when you do your storyboard, and also in preparation for
your improvement journey.
He does then move to some foreground evidence where he's looking at a clinical
practice guideline for laboratory standards that he references and
cites in order to provide evidence for his improvement project.
And then he also provides some foreground evidence of his institution and
what the rates of infection are for his specific institution.
So for chapter two, in this theory burst, finding scientific evidence to apply for
clinical improvement, we covered three major areas.
The first is the link between evidence and
the context of care, and that finding evidence and asking questions is
different than the application in the context of the carrier delivery.
Second, we've found out about asking the right questions.
There's the table on page 25 that will be essential for
you to refer to in order to find out what might be good questions to ask, and
then where would you go to find those resources.
And lastly, we talked about filtered and unfiltered evidence and
that filtered evidence is evidence that has been taken from the literature and
used to create a synthesis.
Unfiltered evidence is specific and original from the author. And
that concludes our module two on evidence,
literature, and industry assessments.
Now I'd like for you to go to the tab on module two that will be the direct link to
the application of this theory to your practice.
