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Why is understanding the health care system at the local level important to consider when planning an EBP implementation?

Why is understanding the health care system at the local level important to consider when planning an EBP implementation?

Why is understanding the health care system at the local level important to consider when planning an EBP implementation?
QUESTION
Why is understanding the health care system at the local level important to consider when planning an EBP implementation? Conduct research and solicit anecdotal evidence from your course mentor that you will take into consideration for your own change project. ( PATIENTS WITH CANCER)

Why is understanding the health care system at the local level important to consider when planning an EBP implementation?

ANSWER
Although evidence-based practice is regarded as the gold standard in patient care, research indicates that it takes hospitals and clinics approximately 17 years to adopt a practice or treatment after the first systematic evidence demonstrates that it benefits patients.

Why such a long delay when the patient’s health is at stake? Part of the problem is the difficulty in adapting practices to the environment. Attempting to “plug in” a new practice to a different hospital or clinic frequently clashes with existing practices and meets with resistance from care providers. Deviating from the evidence-base, on the other hand, can undermine the practice’s effectiveness and reduce its benefits. Leaders must strike a balance between adhering to standards and tailoring to the local context.

We’ve outlined four approaches to help health care leaders adapt evidence-based practices while staying close to the foundational evidence based on our research on organizational change and conversations with hundreds of healthcare providers. These approaches are based on 1) data, 2) resources, 3) goals, and 4) preferences of an organization. Each of these approaches has its own set of opportunities and challenges, and in order for any of them to succeed, the local context and people must be understood. It is also critical to consider any legal or professional constraints that may limit options. In practice, the shift to standardization and best practices reduces rather than increases risks because they frequently replace idiosyncratic or outdated practices and preferences.

Recognize the data: How applicable is the evidence to our specific situation?
Sometimes you have to modify a practice because the data behind it does not apply to your specific situation. What if the evidence-base is compiled from various patient populations, hospitals with varying structures or cultures, or countries with varying regulatory environments and payment structures? Some practices will be more generalizable than others (for example, the evidence supporting the importance of hand hygiene is applicable across most contexts), and understanding the data assists in objectively determining appropriate modifications (e.g., changing certain medication dosages based on patient age and BMI). When adapting evidence-based practices to the local context, it is critical to consider what is similar, what is different, and why these differences may be significant.

Leaders should also consider whether existing data is sufficient to support implementing a new practice (in its original or modified form), or whether additional data should be collected to verify efficacy prior to a widespread roll-out. Improved recovery practices, for example, advocate for early patient ambulation following surgery. However, the majority of the initial research was conducted on young adult patients rather than elderly patients. As a result, more research was required to determine whether the practice needed to be modified for a patient population that is more frail and at a higher risk of falling. Notably, even after the adapted evidence-based practice is implemented, more data should be collected to allow for ongoing reassessment and, if necessary, adjustment.

Examine your resources: how can we make substitutions without sacrificing results?
Organizations must sometimes adapt based on resources. Are the resources used in the original implementation not feasible or desirable in one’s own context? Infrastructure, supplies, space, and personnel are examples of resources. Many smaller hospitals, for example, cannot afford to administer the same brand-name drugs as major academic research hospitals. As a result, they may need to substitute and/or combine other medications to achieve the same results.

Responsiveness to evidence-based practices shifts from “we don’t have the resources to do that” to “how can we apply these practices with the resources we do have?” To determine the appropriate substitutes, adaptations necessitate understanding the purpose or goal of the new practice. For example, hospitals that do not have sophisticated electronic health records may be unable to implement electronic patient smart order sets, but they can achieve similar improvements in care coordination by using paper checklists. Collecting additional data on the customized resources can also help ensure that substitutes achieve similar results to the initial evidence-based research when making resource-based adaptations.

Define your objectives: What are our objectives, and how can we achieve them?
The goal of implementing an evidence-based practice should not be the act of doing so. Defining your goals in terms of a patient-centered outcome will assist you in making appropriate changes. Many hospitals, for example, strive to reduce inpatient length of stay. If the change leaders concentrate solely on the inpatient length of stay, they may develop a program that rushes the patient out of the hospital before they are ready. If the goal is to improve recovery from illness or surgery, the emphasis shifts to the patient experience, and the reduction in inpatient length of stay is simply the byproduct of a provider and patient-friendly program.

When there isn’t enough data to guide local adaptations, understanding the overarching goals of new practices can help. Consider how dynamic pain control innovations developed for major in-patient procedures can be adapted for minor out-patient procedures. Keeping the goal of dynamic pain control in mind, providers can prescribe different preoperative pain medications for minor outpatient procedures that manage pain without the drowsiness associated with in-patient medications.

Determine your preferences: How can we make adoption easier?
Personal preferences of powerful individuals or coalitions of care providers are all too often used to determine whether or not to implement evidence-based practices. When a health-care system transitioned to a standardized set of tools and equipment, physicians preferred specific tools (for example, surgical staples or scalpels) because that is what they had been trained on. Despite evidence that these tools were three times more expensive and had no effect on patient outcomes, physicians continued to request them.

Preferences based on subjective, idiosyncratic reasoning prevent the adoption of new approaches that can improve health outcomes, reduce costs, and reduce errors. As a result, health-care leaders must investigate why providers have certain preferences. Some people prefer how evidence-based practice is implemented rather than what it is.

Care providers, for example, may be willing to use specific equipment for a procedure if it is easily accessible. When inserting a central venous catheter, providers should clean the skin with chlorhexidine antiseptic, use a sterile drape/dressing, and wear a sterile mask, hat, gown, and gloves to avoid surgical site infections. Why not make it easier for caregivers to use all of these items by packaging them together in a convenient location? Similarly, providing training on new tools or techniques allows caregivers to learn more about them and become more comfortable with them.

Leaders can encourage adoption without revising the core elements of evidence-based practices if they make compliance with the new practices as simple as possible.

Changing your approach
When deciding whether and how to adapt evidence-based practices within legal and professional guidelines, you must consider both technical and human factors.

In our experience, starting with the original source data provides the most fidelity to the desired outcomes and allows for objective customization decisions. Then, facilitate discussions about how a specific practice should be adapted locally. Consider substitutes that would address these concerns while still achieving the results that the evidence supports if providers’ responses include reservations about available resources. Engaging users in how to best use existing resources to implement new practices fosters process ownership.

If staff questions the new best practice, reaffirming the higher-order goals may help explain why adopting the evidence-based practice is critical. Alternatively, if the resistance is based on language like “I like” and “I want,” try to understand the underlying preferences and values. Consider alignment with other practices and try to create innovative solutions for preferences related to how the practice is enacted. Discuss the higher order goals and what the research supports for preferences related to the content of the practice. Users are more open to how “we could achieve our goals” by using what “the research shows” when they share a commitment to these goals.

Listen to the context and your people, and then revise the new practice as needed. Leaders who can move fluidly between these approaches develop a disciplined and adaptive approach to implementing evidence-based practice — one that encourages collaborative problem solving, facilitates agreement, and alleviates the tensions associated with tailoring research recommendations.

Why is understanding the health care system at the local level important to consider when planning an EBP implementation?

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