Action Plan for Translating Research Into Practice: Gap Analysis and Tests of Change: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Action Plan for Translating Research Into Practice:
Gap Analysis and Tests of Change
Slide 2: Learning Objectives
After this session, you will be able to–
- List steps of Translating Research Into Practice (TRIP) framework.
- Define gap analysis.
- List principles of test of change.
- Pilot test of change and collect data to evaluate potential intervention.
Slide 3: Model for Improving Care1-2
Image: Graphic showing the combination Comprehensive Unit-based Safety Program (CUSP) and TRIP model for solving local and common problems through the use of adaptive work and technical work.
1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008 Oct 6;337:a1714. PMID: 18838424.
2. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care 2008 Jun;23(2):207-21. PMID: 18538214.
Slide 4: Translating Research Into Practice1
Image: Graphic displaying TRIP framework: 1. Summarize evidence, 2. Identify local barriers, 3. Measure performance, 4. Ensure all patients receive the interventions.
1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008 Oct 6;337:a1714. PMID: 18838424.
Slide 5: Summarize the Evidence1
Image: Summarize the Evidence: 1. Identify interventions; 2. Prioritize interventions with the largest benefits and lowest barriers; 3. Implement interventions to foster new behaviors.
1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008 Oct 6;337:a1714. PMID: 18838424.
Slide 6: Identify Local Barriers1
Image: Identify local barriers to implementation: 1. Observe staff performing care delivery tasks; 2. Walk the process to identify defects at each step; 3. Solicit feedback from all stakeholders and Identify potential gains or losses.
1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008 Oct 6;337:a1714. PMID: 18838424.
Slide 7: Identify Local Barriers
- Walk your process.
- Perform a gap analysis between current performance and the ideal state.
- Use several sources of information:
- Capture baseline data for daily care processes and early mobility measures.
- Speak with multiple providers with varying levels of expertise both in the field and in the unit.
- Seek multidisciplinary representation.
Slide 8: Measure Performance1
Image: Measure performance: 1. Select process and/or outcome measures; 2. Develop and pilot test measures; 3. Measure baseline performance.
1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008 Oct 6;337:a1714. PMID: 18838424.
Slide 9: Measure Performance
- Identify metrics to define the current practice and to track progress over time.
- Collect data on current practice.
- Create a vision for desired state and share it with entire unit.
- Modify that vision through an iterative process until it reflects the unit’s shared vision.
Slide 10: GAP Analysis
Find the differences between evidence-based care and current practice.
Slide 11: GAP Analysis
Image: Line graph that illustrates the difference between current performance and the ideal state.
Slide 12: Unit-Based Gap Analysis3
- The unit-based gap analysis tool was developed by the American Association of Critical Care Nurses (AACN).
- Originally designed to be used in conjunction with one of the AACN’s bedside technical intervention bundles but can be effectively applied to any process within your specific unit.
- Respondent uses a Likert scale to record the frequency in which an activity or procedure is performed.
Image: Example of Likert scale used to record the frequency in which an activity or procedure is performed.
3. Unit Gap Analysis. Implementing the ABCDE Bundle at the Bedside: American Association of Critical-Care Nurses. http://www.aacn.org/wd/practice/content/actionpak/withlinks-ABCDE-ToolKit.content?menu=practice. Accessed March 8, 2016.
Slide 13: Unit-Based Gap Analysis3
Sedation, SAT, and SBT Protocols:
- Our unit uses a sedation and analgesia protocol consistent with the Pain, Agitation, and Delirium guidelines.
- We routinely perform both pain and sedation assessment on patients using a validated tool.
- We currently perform spontaneous awakening trails (SATs) daily on all patients receiving sedation.
- We use a standardized protocol for performing SATs.
- We use a standardized protocol for performing spontaneous breathing trials (SBT).
Image: Example of Likert scale used to record the frequency that an activity or procedure is performed.
3. Unit Gap Analysis. Implementing the ABCDE Bundle at the Bedside: American Association of Critical-Care Nurses. http://www.aacn.org/wd/practice/content/actionpak/withlinks-ABCDE-ToolKit.content?menu=practice. Accessed March 8, 2016.
Slide 14: Unit-Based Gap Analysis3
Delirium Assessment and Management:
- All patients are assessed daily for the presence of delirium.
- We use a validated tool to assess for the presence of delirium (Confusion Assessment Method for the ICU or Intensive Care Delirium Screening Checklist).
- Our unit has a standardized delirium management protocol.
- Delirium monitoring is included in our daily rounds for ALL patients.
Image: Example of Likert scale used to record the frequency that an activity or procedure is performed.
3. Unit Gap Analysis. Implementing the ABCDE Bundle at the Bedside: American Association of Critical-Care Nurses. http://www.aacn.org/wd/practice/content/actionpak/withlinks-ABCDE-ToolKit.content?menu=practice. Accessed March 8, 2016.
Slide 15: Unit-Based Gap Analysis3
Early Exercise and Progressive Mobility:
- Our unit has a protocol for early exercise and progressive mobility for ALL patients.
- Immobile patients on our unit receive passive range of motion regularly, if tolerated.
- Our unit has the necessary support equipment to safely assist with patients’ increased mobility.
- Respiratory therapists and physical therapists are available to assist with implementing early exercise and progressive mobility protocols.
- Mobility is addressed during daily rounds.
Image: Example of Likert scale used to record the frequency that an activity or procedure is performed.
3. Unit Gap Analysis. Implementing the ABCDE Bundle at the Bedside: American Association of Critical-Care Nurses. http://www.aacn.org/wd/practice/content/actionpak/withlinks-ABCDE-ToolKit.content?menu=practice. Accessed March 8, 2016.
Slide 16: Bridge the Gap
- Use the gap example to sell the project, garner buy-in, and create energy to accelerate change.
- List and prioritize defects and changes required to achieve your objectives.
- Explore why the defects exist:
- Drill down.
- Ask Why, Why, Why?
- Create a plan to move from current to target condition:
- Assess then address cultural barriers.
- Include project management support.
- Incorporate change management techniques.
Slide 17: Ensure All Patients Receive the Evidence (4Es)1
Image: Chart depicts the 4 Es:
- Engage: How can we engage hearts and minds?
- Educate: How can we turn the evidence into behaviors?
- Execute: How can we do this?
- Evaluate: How do we know if we made a difference?
1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008 Oct 6;337:a1714. PMID: 18838424.
Slide 18: Translating Evidence Into Practice1
Image: Graphic displaying TRIP framework: 1. Summarize evidence, 2. Identify local barriers, 3. Measure performance, 4. Ensure all patients receive intervention.
1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008 Oct 6;337:a1714. PMID: 18838424.
Slide 19: Summary
- Gap exists between evidence and practice regarding sedation and mobility.
- Undertake change at the local level.
- Perform gap analysis between your current practice and future state (where you want to be—your vision).
- Set goals to improve care.
Slide 20: Tests of Change
How small-scale tests inform sustainable quality improvement efforts.
Slide 21: Basics of Tests of Change4-6
Image: Table lists the following basics:
- Define: Small-scale tests to evaluate proposed change.
- Goal: Test potential improvement to unit’s workflow with potential to transform care.
- Benefits:
- Provides rapid real-time feedback.
- Allows iterative adjustment.
- Offers action-oriented learning.
4. Science of Improvement: Testing Changes. How to Improve: Institute for Healthcare Improvement. 2015. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx. Accessed March 8, 2016.
5. Principles for Tests of Change. Robert Wood Johnson Foundation. 2008. http://www.rwjf.org/en/research-publications/find-rwjf-research/2008/06/the-transforming-care-at-the-bedside-tcab-toolkit/section-3-testing-ideas/principles-for-tests-of-change.html. Accessed March 8, 2016.
6. Principles for Rapid Cycle Tests. Robert Wood Johnson Foundation. 2008. http://www.rwjf.org/content/dam/farm/toolkits/toolkits/2008/rwjf26881. Accessed March 8, 2016.
Slide 22: Reasons to Test Change4
- Increase belief that change will result in improvement.
- Decide which of several proposed changes will lead to desired improvement.
- Evaluate how much improvement can be expected from the change.
- Decide whether the proposed change will work in the actual environment of interest.
4. Science of Improvement: Testing Changes. How to Improve: Institute for Healthcare Improvement. 2015. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx. Accessed March 8, 2016.
Slide 23: Reasons to Test Change4
- Decide which combinations of changes will have desired effects on key measures of quality.
- Evaluate costs, social impact, and side effects to a proposed change.
- Minimize resistance upon implementation.
4. Science of Improvement: Testing Changes. How to Improve: Institute for Healthcare Improvement. 2015. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx. Accessed March 8, 2016.
Slide 24: Principles for Tests of Change6
- Test to evaluate if a new idea or innovation will work.
- Test small (n=1):
- One nurse.
- One shift.
- One patient.
- One shift change report.
- Engage an informed tester who is invested in the process.
6. Principles for Rapid Cycle Tests. Robert Wood Johnson Foundation. 2008. http://www.rwjf.org/content/dam/farm/toolkits/toolkits/2008/rwjf26881. Accessed March 8, 2016.
Slide 25: Principles for Tests of Change
- Don’t wait for a committee approval.
- Form a hypothesis and collect data (quantitative and qualitative).
- Go to the committee after test with data to support proposed changes.
- Revise–it takes many iterations to build innovations.
Slide 26: Plan-Do-Study-Act (PDSA) Cycle4
PDSA is the core of the Institute for Healthcare Improvement’s Model for Improvement
Image: PDSA Cycle chart with three questions. 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in improvement?
4. Science of Improvement: Testing Changes. How to Improve: Institute for Healthcare Improvement. 2015. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx. Accessed March 8, 2016.
Slide 27: PDSA Cycle for Learning and Improvement4
Image: Graphic of PDSA cycle specific to learning and improvement.
4. Science of Improvement: Testing Changes. How to Improve: Institute for Healthcare Improvement. 2015. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx. Accessed March 8, 2016.
Slide 28: PDSA Step 1: PLAN
Plan test, including data collection plan:
- State test objectives.
- Make predictions about what will happen and why.
- Develop a plan to test the change:
- Who?
- What?
- When?
- Where?
- What data need to be collected?
Slide 29: PDSA Step 2: Do
Try out the test on a small scale:
- Carry out the test.
- Document problems and unexpected observations.
- Collect and begin data analysis.
- Keep data collection as simple as possible.
Slide 30: PDSA Step 3: Study
Set aside time to analyze data and study results:
- Analyze data.
- Compare the data with predictions.
- Summarize and reflect on what was learned.
Slide 31: PDSA Step 4: Act
Refine change, based on what was learned from test:
- Determine what modifications are needed.
- Adapt test to reflect new information.
- Prepare a plan for the next test.
- Abandon test if necessary.
Slide 32: Test of Change Examples6-7
- Implement weekly updates of data sharing with unit to show progress.
- Elicit daily goals with new script.
- Give incentive to document new care procedure:
- Appreciate good work.
- Remind nurses to continue documentation.
- Include reminder of 10 a.m. spontaneous awakening trial target at both daily nurse huddles.
6. Principles for Rapid Cycle Tests. Robert Wood Johnson Foundation. 2008. http://www.rwjf.org/content/dam/farm/toolkits/toolkits/2008/rwjf26881. Accessed March 8, 2016.
7. Klompas M, Anderson D, Trick W, et al. The preventability of ventilator-associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative. Am J Respir Crit Care Med 2014 Nov 4. PMID: 25369558.
Slide 33: Sample Test of Change7
Image: Table lists sample tests for Spontaneous Awakening Trials (SATs):
- Plan: Raise SAT compliance rate by reminding nursing staff of 10 a.m. SAT target time.
- Do: On Monday, add daily reminder at 7 a.m. nurse huddle of 10 a.m. SAT target.
- Study: Analyze current data. Did more patients receive SAT at 10 a.m.?
- Act: Add reminder of 10 a.m. SAT target to both 7 a.m. and 7 p.m. daily nurse huddles.
7. Klompas M, Anderson D, Trick W, et al. The preventability of ventilator-associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative. Am J Respir Crit Care Med 2014 Nov 4. PMID: 25369558.
Slide 34: Planning Questions
- What do you need to test the idea?
- Who will be involved in the test?
- How will you educate participants?
- Where will test occur?
- When will test occur?
- What is the expected outcome?
- How will you know it is successful?
Slide 35: Share Your Test of Change
- What did you predict would happen?
- What happened?
- What did you learn?
- What are your next steps?
Slide 36: Next Steps
- Identify measurable goal of proposed change.
- Test under multiple conditions.
- Test with a variety of staff.
- Review all feedback.
- Be forward thinking and flexible.
- Revise proposal until concerns are addressed.
Slide 37: Questions?
Image: Multicolored hanging tags with question marks on them.
Slide 38: References
1. Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008 Oct 6;337:a1714. PMID: 18838424.
2. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care 2008 Jun;23(2):207-21. PMID: 18538214.
3. Unit Gap Analysis. Implementing the ABCDE Bundle at the Bedside: American Association of Critical-Care Nurses. http://www.aacn.org/wd/practice/content/actionpak/withlinks-ABCDE-ToolKit.content?menu=practice. Accessed March 8, 2016.
4. Science of Improvement: Testing Changes. How to Improve: Institute for Healthcare Improvement. 2015. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx. Accessed March 8, 2016.
Slide 39: References
5. Principles for Tests of Change. Robert Wood Johnson Foundation. 2008. http://www.rwjf.org/en/research-publications/find-rwjf-research/2008/06/the-transforming-care-at-the-bedside-tcab-toolkit/section-3-testing-ideas/principles-for-tests-of-change.html. Accessed March 8, 2016.
6. Principles for Rapid Cycle Tests. Robert Wood Johnson Foundation. 2008. http://www.rwjf.org/content/dam/farm/toolkits/toolkits/2008/rwjf26881. Accessed March 8, 2016.
7. Klompas M, Anderson D, Trick W, et al. The preventability of ventilator-associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative. Am J Respir Crit Care Med 2014 Nov 4. PMID: 25369558.
