ebp when rubber meets the road header
Marcie Hopkins, University of Utah Health
leadership
When Rubber Hits the Road: Applying Evidence in Clinical Decision Making
The next step in the evidence-based practice (EBP) process is to apply findings to clinical decision making—implementing the EBP project.

Case Study

Niladri, a physician assistant working in the diabetes clinic, found some studies which support community gardens as ways to improve nutrition in diabetic patients. He wants to partner with a community garden and offer a county-wide program for diabetic patients. Niladri plans to host a series of workshops and lectures at the community garden about diabetes and healthy eating. He wants to promote the new program to all the patients in the diabetes clinic and throughout the community. He thinks the participants could work in the garden and learn more about nutrition. How should he plan to implement this evidence-based plan?

O

nce you have completed your literature search and rapid critical appraisal, you are ready to act based on your findings. The fourth step in the EBP process is to apply your findings to clinical decision making. In this step, you’ll integrate the findings from your literature search into practice.

As you do this, remember to also consider clinical expertise and patient preferences and values. From there you can make evidence-based recommendations for day-to-day practice. The apply step corresponds with the implementation of your EBP project. For this module, we will refer to the apply step as the implementation of the EBP project.

Planning steps

1. Consider a pilot: determine project scope and feasibility

The first question to ask yourself is, “What is the scope of my project?” In other words, where does the process start, where does it end and who are the patients and/or staff that will be impacted by the project? 

You’ll also need to ask yourself, “Is this a manageable-sized project?” Is the size of your project manageable to implement all at the same time? If not, you might want to consider implementing your plan in phases or consider running a pilot—a small-scale version of your project—before implementing it on a large scale. 

Using a pilot is helpful to understand the impact that your project might have on the current process and the staff involved in that process without involving multiple areas and staff. It’s also helpful in identifying the possible barriers to implementation. A smaller-scale project provides you with the ability to better address those issues.

For the purpose of this module, let’s say that we decided to run a small-scale pilot first before implementing a large-scale project. For Niladri, that may mean offering a workshop for a few patients at his clinic about healthy eating and asking the community garden director to speak about their work. An additional phase of the pilot may mean spending a weekend working together in the community gardens. Niladri could use a pre- and post-survey to gauge nutrition knowledge and community garden interest. 

There are some things to consider when running a pilot:

  • Determine how long it will take to know that your pilot is successful and include that timeframe into your overall plan (you’ll need to have a good understanding of your outcome measures - skip to step 5).

  • Provide close support during the pilot to promote a positive outlook towards the change. 

  • Ask for feedback from those impacted by the change so you can determine if you need to make any adjustments. Be flexible to make changes based on the feedback.

2. Form your team

Implementing a project can be more easily accomplished with the help of a team. Do you have a representative from every job function that the project will impact? It will be important to consider their perspectives and helpful to have their support when trying to get buy-in from their respective groups. Also identify who from the team can assist with the actual implementation process. How do you recruit their assistance and how can they help support you?

3. Identify and engage stakeholders and secure administrative support 

In order for your project to be successful, ensure that you have buy-in and support from the appropriate stakeholders. Does your project need approval from organization or department leadership? A sponsor is a leader who believes in your project. Including a sponsor from these decision-making bodies can help you with barriers that might occur during project implementation.        

Stakeholders are staff outside of your team that you will have to engage to implement the change. Be sure to include them. How will the implementation of your project impact them? How will you let everyone know what your project is intended to improve? Are they aware and informed of the change in practice and your monitoring efforts? This communication can be provided in staff meetings, education sessions, flyers, email notification, campaigns, etc. 

The best way to understand your stakeholders’ needs and perspectives is to involve them in the review and implementation of your project. They can also provide needed education, support and role modeling to help champion the changes you are implementing.

4. Identify and assemble resources 

It’s important to identify and assemble the resources you need for the implementation of your project. For example, do you have the human resources that are needed to make data, protocol and EMR changes as well as to monitor the process? Consider the groups that are needed to help make your project implementation successful. For example, groups such as Nursing Informatics, Decision Support, System Quality, Data Warehouse, Value Engineering, Epic IT, Nursing Education, Equipment Management and Pharmacy, etc., could help.

5. Think ahead: measure outcomes 

How to evaluate an EBP project will be addressed in the next module but it helps to start thinking about that step now so you can determine how to measure success. First, identify what you will measure in order to know that your project is successful. Ask yourself these questions:

  • How do you know that there is a problem now?

  • How do you know that your intervention has changed the problem?

  • How will you know in a year whether the problem is still solved?

The final part of your implementation plan is to determine how you will evaluate your project.

6. Plan ahead for success 

Finally, plan ahead for success. Think ahead of what types of barriers and obstacles you could encounter and how you will deal with them. For example, many people are resistant to change and therefore may also resist your project. How will you obtain the support you need for your project to successfully implement change?                           

Another thing to consider is how to ensure that the change is sustained. How will you make sure that the people involved in the implementation of the process will actually perform the new process? This is often overlooked or “solved” by assuming people will just remember it. Research has shown that after education is provided, the changes as a result of the education are sustained in a process for about six months. What methods have you placed into the process that will support the staff? Some ways to make sure that people will perform the new process is to create:

  • A physical mechanism, like a needle cap

  • A computer or automated tool, like an alert in Epic

  • A manual tool like a checklist

  • Or a visual reminder like a fall risk sign

Now that you have a plan, it’s time to set a go-live date and pilot your implementation.  Communication is key to having a successful pilot and being transparent about your plan with the pilot area will provide everyone with the knowledge and direction needed for a smooth implementation. Be sure all involved have the opportunity to be informed of the change in practice and your monitoring efforts. Transparency goes a long way so be sure to communicate the success or barriers to your team and the stakeholders involved.

Next steps 

After you complete your initial pilot, what are your next steps? It’s time to decide whether to continue to do additional small area implementations or to roll your project out to the entire scope as initially intended. Whatever you do, you will need to consider the following:

  1. Have the stakeholders changed? Ensure you have support by identifying any new stakeholders. How will you inform them of what your project is intended to improve, the change in practice and your monitoring efforts? Can some staff from this group be recruited to assist in the data gathering process as well as champion the implementation of the project?

  2. Evaluate success and consider lessons learned. If you performed a pilot before taking your project on a wider scale, consider the lessons learned from the feedback provided by your pilot group. How will you integrate this information and adjust your project to make it more successful? With these adjustments or simply because your project will be implemented on a larger scale, will additional resources be needed? 

Knowing the answers to these questions ahead of time will help you be successful in implementing your project on the larger scale.

Contributors

Barbara Wilson

Associate Professor, College of Nursing, University of Utah Health

Mary-Jean (Gigi) Austria

Nurse Manager, Clinical Staff Education, Huntsman Cancer Hospital, University of Utah Health

Tallie Casucci

Assistant Librarian, Marriott Library, University of Utah

Cindy Spangler

Senior Value Engineer, University of Utah Health

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