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The Joanna Briggs Institute clinical fellowship program: a gateway opportunity for evidence-based quality improvement and organizational culture change

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There are many benefits to the uptake of EBHC, not just in terms of practice improvement, but also in understanding individual and organisational barriers and facilitators and the process of change itself. However, a lack of autonomy in the strategic and cultural domains of healthcare organization and delivery, is problematic. The JBI Evidence Based Clinical Fellowship Program (EBCFP) overcomes this, by providing foundational knowledge on change management, leadership, implementation, and evaluation. A constructionist approach enables participants to situate and ground their learning in their own clinical experience, expertise, and interests, all of which facilitate the translation of research into practice. The Joanna Briggs Institute best evidence programs, tools, and resources bridge the evidence to practice gap, and enable organizations to up-skill and equip their clinical staff with specific skills, knowledge and resources. As such, the JBI programs can be considered gateway programs for practice change. An organisational culture of Best Practice requires investment in nurses and other front-line staff as clinical leaders, as innovators, and as drivers of healthcare quality. Organizational as well as individual benefits of the JBI EBCFP include increased capacity for clinical leadership through clinicians and carers who are equipped for practice with the knowledge, skills and resources to lead evidence-based practice change, and to facilitate an organizational culture of improvement.
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The Joanna Briggs Institute clinical fellowship
program: a gateway opportunity for
evidence-based quality improvement
and organizational culture change
Practising health professionals trained and prepared for
best practice lead the provision of high quality, evidence-
based healthcare (EBHC), as many researchers have con-
sistently demonstrated.
1–5
Nurses in particular have a
high level of knowledge and acceptance of EBHC, high
uptake of EBHC principals in undergraduate and post-
graduate nursing programs, and increasing integration of
evidence in nurse-led quality improvement initiatives.
6–9
There have been many benefits to the uptake of EBHC, not
just in terms of practice improvement, but also in under-
standing individual and organizational barriers and facil-
itators and indeed the process of change itself.
10– 13
However, nurses are not always professionally enabled
to contribute to EBHC initiatives.
14,15
While EBHC has
supported nurses to make substantive contributions to
professional nursing knowledge and practice, there are
still gaps. A lack of autonomy in the strategic and cultural
domains of healthcare organization and delivery is prob-
lematic.
16
Without mechanismsto address these systemic,
organizational issues, the promise and potential contribu-
tion of nursing will not be fully realized.
The Joanna Briggs Institute (JBI) was established as an
international research institute in 1996 with a vision for a
world in which the best available evidence is used to
inform policy and practice to improve health in commu-
nities globally.
17
While many associate JBI with system-
atic reviews of the best available evidence, that is only
one element of their work. JBI is also involved with
knowledge transfer and knowledge implementation as
the JBI Model (Fig. 1) illustrates.
The JBI Evidence-Based Clinical Fellowship Program
(EBCFP) focuses on implementation and was designed
for busy healthcare practitioners, managers, and admin-
istrators, who have an interest in implementing best
practice, but may not have familiarity with the suite of
skills needed to lead and sustain practice change.
18,19
The program is delivered over 6 months; participants
attend an intensive 1-week workshop that provides
foundational knowledge on change management,
leadership, implementation, and evaluation. Following
the workshop, participants return to their clinical insti-
tution, where they conduct a rapid cycle small test of
change following a Model of EBHC.
14
After they have
collected baseline data, and implemented their change
based on best practice, participants return for a second
intensive residency, in which they work in small groups
to analyse and evaluate their data and work on dissemi-
nation. This constructionist approach enables partici-
pants to situate and ground their learning in their
own clinical experience, expertise, and interests, all of
which facilitate the translation of research into practice.
Programs such as the EBCFP are designed to help
improve the safety and quality of care provided in health
facilities; and facilitate the development of clinical auton-
omy in the strategic and cultural domains of healthcare
organization and delivery. This is a complex process that
crosses systems, resources, infrastructure, and policy and
process requirements, and requires situated contextual
know-how and operational leadership necessary for
patient and family care. Instituting a change based on
best practice needs to utilize a programmatic, standard-
ized approach that promotes the use of systems and
infrastructure to address issues of policy or practice at
the organizational level. This in turn, contributes to the
promotion of key indicators (such as hand hygiene or
surgical patient management) aligned with national or
international accreditation and benchmark standards.
The achievement of such key indicators is by neces-
sity a multidisciplinary endeavour. Graham et al.
20
and
Steel-Moses
21
argue that embarking on a trajectory for a
substantive strategic goal requires a whole of organiza-
tion investment. It involves a mission driven investment
that recognizes the value of nurses and their contribu-
tion to clinical leadership and policy and practice
improvement. Graham advocates for the use of a process
similar to that described in the knowledge to action
model for leveraging change processes based upon a
call to action that includes a situational analysis and total
International Journal of Evidence-Based Healthcare ß2020 University of Adelaide, Joanna Briggs Institute 1
EDITORIAL
©2020 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
organizational engagement for implementation of
EBHC.
20
The need for a roadmap and steps in planning
aligns well with the work of Steele-Moses,
21
who also
advocate for a gap analysis to inform the scope of work,
effective planning, inclusivity of top down support for
clinical practice transformation, and adequate resourcing
of the planning phase.
21
Adequate resourcing includes
finance, staff time, integration with relevant committees,
and regular high-level program activity review.
21
JBI Clinical Fellows work with other clinicians, admin-
istrators and managers as required to scope the problem
and develop a plan for implementing best practice to
address the compliance gaps found in the baseline audit.
The implementation phase is a facilitated project that
starts with the identification of potential barriers to best
practice, moves to solution building where strategies to
overcome the barriers are developed, and the resources
needed to implement are identified. As per the JBI
Model, the facilitation of change is step two in the
implementation of best practice and is where most of
the fellowship time is allocated. Implementation contin-
ues through an evaluation cycle that provides
Figure 1. The Joanna Briggs Institute model of evidence-based healthcare.
EDITORIAL
2International Journal of Evidence-Based Healthcare ß2020 University of Adelaide, Joanna Briggs Institute
©2020 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
measurable data on care processes and patient out-
comes that were identified as important during the
context analysis.
The JBI suite of best evidence programs, tools, and
resources facilitate the implementation of change based
on best practice, and surveys consistently demonstrate
that clinicians possess both the knowledge and motiva-
tion to participate and indeed lead such programs of
work. By bridging the evidence to practice gap, and
enabling organizations to up-skill and equip their clinical
staff with specific skills, knowledge and resources, the JBI
programs can be considered gateway programs for
practice change.
Investing in nurses and the practising professions as
clinical leaders, innovators, and drivers of healthcare
quality is well supported by high-quality systematic
reviews. Creating a collective organizational culture of
improvement, as well as the tangible individual benefits
of the JBI EBCFP include honing important project man-
agement skills, instilling a sense of empowerment and
mastery, and increasing capacity for clinical leadership
by the clinicians and carers who are equipped with the
knowledge, skills and resources to lead evidence-based
practice change. Investing in staff for EBHC is something
we can all support.
Acknowledgements
Conflicts of interest
The authors report no conflicts of interest.
Craig Lockwood PhD,
1
Daphne Stannard PhD, RN,
2
Zoe Jordan PhD
1
and Kylie Porritt PhD, RN
1
1
Joanna Briggs Institute, University of Adelaide, Adelaide,
South Australia, Australia,
2
Adult Medical/Surgical & EBP/
Nursing Research, San Francisco State University,
San Francisco, California, USA
Correspondence:
Dr Craig Lockwood, PhD, Director
Implementation Science, Joanna Briggs Institute, Floor 3,
55 King William Road, Norwich Centre, North Adelaide,
Adelaide 5006, SA, Australia.
E-mail:
craig.lockwood@adelaide.edu.au
DOI:10.1097/XEB.0000000000000221
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EDITORIAL
4International Journal of Evidence-Based Healthcare ß2020 University of Adelaide, Joanna Briggs Institute
©2020 University of Adelaide, Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
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Background: Supporting and involving the families of pre-term infants' in the discharge process provides them with confidence in caring for their infants at home. In an effort to facilitate families' readiness for discharge, the neonatal unit (NU) of the Children's Hospital of Fudan University has implemented a best practice project. Objectives: The aim of this project was to integrate the best available evidence on facilitating families' readiness for discharge into the nursing practice of the Children's Hospital of Fudan University. Methods: The current evidence implementation project utilized the Joanna Briggs Institute (JBI) Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice audit (GRiP) and feedback tools. Nine audit criteria were established on the best available evidence. The project was divided into three phases and conducted over six months in the NU. Results: Follow-up audits showed significant improvements. The most significant improvements, 95% compliance, were found in family involvement on admission, formal assessment of the family's caregiving capabilities, psychosocial readiness, resource availability and preferred teaching style. A moderate increase was noted in identification of family members involved (65%), formal assessment of their learning needs (50%) and provision of tailored education (55%). A small increase of 25% in compliance was found for evaluation of the education. Conclusion: The project led to various changes, such as early involvement of pre-term infants' families, a formal assessment of their readiness for caring for infants and a tailored education program. Further audits will need to be carried out to sustain behavior change and monitor any areas for improvements.
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Background: Heart failure is a major public health concern which contributes significantly to rising healthcare costs. Comprehensive discharge planning can improve health outcomes and reduce readmission rates which, in turn, can lead to cost savings. Objectives: The aim of this project was to promote best practice in the discharge planning of heart failure patients admitted in the coronary care unit of Zhongshan Hospital. Methods: A clinical audit was undertaken using the Joanna Briggs Institute Practical Application of Clinical Evidence System tool. Five audit criteria that represent best practice recommendations for heart failure discharge planning were used. A baseline audit was conducted followed by the implementation of multiple strategies, and the project was finalized with a follow-up audit to determine change in practice. Results: Improvements in practice were observed for all five criteria. The most significant improvements were in the following: completion of a discharge checklist (from 0% to 100% compliance), comprehensive (i.e. inclusion of six topics for self-care) discharge education for patients (from 7% to 100% compliance), and conducting a telephone follow-up (from 0% to 76% compliance). The compliance rates for the two remaining criteria, completion of a structured education for patients and scheduling an outpatient clinic visit, both increased from 93% to 100%.Strategies that were implemented to achieve change in practice included development of a local discharge planning checklist, provision of training for nurses, and development of resources. Conclusions: The project demonstrated positive changes in the discharge planning practices of nurses in the coronary care unit of Zhongshan Hospital. A formalized discharge planning is currently in place and plans for sustaining practice change are underway. A continuous cycle of audit and re-audit will need to be carried out in the future to determine the impact of this evidence implementation activity on heart failure patient outcomes.
Article
Background: Purposeful and timely rounding is a best practice intervention to routinely meet patient care needs, ensure patient safety, decrease the occurrence of patient preventable events, and proactively address problems before they occur. The Institute for Healthcare Improvement (IHI) endorsed hourly rounding as the best way to reduce call lights and fall injuries, and increase both quality of care and patient satisfaction. Nurse knowledge regarding purposeful rounding and infrastructure supporting timeliness are essential components for consistency with this patient centred practice. Objectives: The project aimed to improve patient satisfaction and safety through implementation of purposeful and timely nursing rounds. Goals for patient satisfaction scores and fall volume were set. Specific objectives were to determine current compliance with evidence-based criteria related to rounding times and protocols, improve best practice knowledge among staff nurses, and increase compliance with these criteria. Methods: For the objectives of this project the Joanna Briggs Institute's Practical Application of Clinical Evidence System and Getting Research into Practice audit tool were used. Direct observation of staff nurses on a medical surgical unit in the United States was employed to assess timeliness and utilization of a protocol when rounding. Interventions were developed in response to baseline audit results. A follow-up audit was conducted to determine compliance with the same criteria. For the project aims, pre- and post-intervention unit-level data related to nursing-sensitive elements of patient satisfaction and safety were compared. Results: Rounding frequency at specified intervals during awake and sleeping hours nearly doubled. Use of a rounding protocol increased substantially to 64% compliance from zero. Three elements of patient satisfaction had substantive rate increases but the hospital's goals were not reached. Nurse communication and pain management scores increased modestly (5% and 11%, respectively). Responsiveness of hospital staff increased moderately (15%) with a significant sub-element increase in toileting (41%). Patient falls decreased by 50%. Conclusions: Nurses have the ability to improve patient satisfaction and patient safety outcomes by utilizing nursing round interventions which serve to improve patient communication and staff responsiveness. Having a supportive infrastructure and an organized approach, encompassing all levels of staff, to meet patient needs during their hospital stay was a key factor for success. Hard-wiring of new practices related to workflow takes time as staff embrace change and understand how best practice interventions significantly improve patient outcomes.
Article
Importance The literature suggests that hospitals with better nursing work environments provide better quality of care. Less is known about value (cost vs quality).Objectives To test whether hospitals with better nursing work environments displayed better value than those with worse nursing environments and to determine patient risk groups associated with the greatest value.Design, Setting, and Participants A retrospective matched-cohort design, comparing the outcomes and cost of patients at focal hospitals recognized nationally as having good nurse working environments and nurse-to-bed ratios of 1 or greater with patients at control group hospitals without such recognition and with nurse-to-bed ratios less than 1. This study included 25 752 elderly Medicare general surgery patients treated at focal hospitals and 62 882 patients treated at control hospitals during 2004-2006 in Illinois, New York, and Texas. The study was conducted between January 1, 2004, and November 30, 2006; this analysis was conducted from April to August 2015.Exposures Focal vs control hospitals (better vs worse nursing environment).Main Outcomes and Measures Thirty-day mortality and costs reflecting resource utilization.Results This study was conducted at 35 focal hospitals (mean nurse-to-bed ratio, 1.51) and 293 control hospitals (mean nurse-to-bed ratio, 0.69). Focal hospitals were larger and more teaching and technology intensive than control hospitals. Thirty-day mortality in focal hospitals was 4.8% vs 5.8% in control hospitals (P < .001), while the cost per patient was similar: the focal-control was −$163 (95% CI = −$542 to $215; P = .40), suggesting better value in the focal group. For the focal vs control hospitals, the greatest mortality benefit (17.3% vs 19.9%; P < .001) occurred in patients in the highest risk quintile, with a nonsignificant cost difference of $941 per patient ($53 701 vs $52 760; P = .25). The greatest difference in value between focal and control hospitals appeared in patients in the second-highest risk quintile, with mortality of 4.2% vs 5.8% (P < .001), with a nonsignificant cost difference of −$862 ($33 513 vs $34 375; P = .12).Conclusions and Relevance Hospitals with better nursing environments and above-average staffing levels were associated with better value (lower mortality with similar costs) compared with hospitals without nursing environment recognition and with below-average staffing, especially for higher-risk patients. These results do not suggest that improving any specific hospital’s nursing environment will necessarily improve its value, but they do show that patients undergoing general surgery at hospitals with better nursing environments generally receive care of higher value.