WHAT, WHERE, WHEN, HOW, & WHY

©Kaiser Permanente

RESEARCH OR PI?

Cecelia L. Crawford RN, DNP; SCAL Regional Nursing Research ProgramLynn M. Garofalo DPPDc, MHA; SCAL Healthcare PI Mentor

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LEARNING OBJECTIVES•At the end of this presentation, the learner will be able to:–State 3 differences between nursing research and performance improvement

–Describe 2 methods to achieve the unique objectives of Research and PI

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THE CONCEPT OF RESEARCH

• Research is not isolated activities or tasks• Surveys, interviews, and observations• Data collection• Statistical analysis• Improvement processes• Evidence-based practice changes

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THE CONCEPT OF RESEARCH

•Research is a rigorous, reproducible, and systematic process that may involve all or part of those tasks and activities

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RESEARCH

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A rigorous & systematic process• Generates new knowledge through the

application of basic scientific principles and theory development

• Overarching intent of research is description, prediction, and control

• Asks “What is not known?”• Final product = new knowledge that can be

generalized in appropriate patient populations©Kaiser Permanente

FACTORS NECESSARY FOR RESEARCH SUCCESS

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• Successful research studies always have these two elements:– A committed research team (not one or two people)

with a passion for the clinical problem• Teams members with various talents, expertise,

and research experience

– An expert researcher to ensure a systematic and research-based approach, who is either:• Part of the research team OR• A consult for the research team

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THE PROCESS OF KNOWLEDGE DEVELOPMENT

(OMERY, 1998)

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Data Facts Information

Analysis Synthesis

Systematic Process

(Organized Data) (Structured & Integrated Facts that are meaningful)

The research process IS the systematic process

that produces scientific knowledge

ScientificKnowledge

EVIDENCE-BASED PRACTICE

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A systematic process• Implements and evaluates interventions

stemming from new knowledge generated by research

• Overarching intent of EBP changes is to integrate scientific discoveries into healthcare practice

• Asks “What is known?” and “What can be done with this knowledge?”

• Final product = systems change and outcome improvement in patient populations

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PERFORMANCE IMPROVEMENT

A structured process that:• Strives to improve system specific

processes and outcomes

• Asks “what is happening and how can it be improved?”

• May contribute new learning & practices

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THE PI PROCESS

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A structured evaluation process with an iterative flow

(SMART Goal) What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

AssessDevelop / Identify Change

Test Implement / Control

Understand the process and decompose the problemO

bjec

tives Generate ideas

for solving the problems

Document the new process

Run PDSA cycles to test ideas

Keep testing ideas until goal is achieved

Implement changes fully into the system

Monitor to sustain; spread if appropriate

Model for Improvement developed by Associates for Process Improvement

Act Plan

Study Do

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FACTORS NECESSARY FOR PI SUCCESS

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• Successful performance improvement projects always have:– A committed improvement team (not one or two

people) with a passion for the problem

–They may also have a PI expert to ensure a structured approach, who is either:• Part of the improvement team OR• A consultant for the improvement team

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RESEARCH & PI• Similarities

• Start with data and analysis

• Have a defined process• Require a committed

team for success• Contributes to

knowledge & outcome improvement

• Differences: • Structures• Processes• Intent• Outcomes• Data required

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STRUCTURE, PROCESS, INTENT, AND OUTCOMES

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DATA REQUIREMENTS

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CASE STUDY: HOSPITAL ACQUIRED PRESSURE ULCERS

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Research

Evidence-Based Practices

Performance Improvement

• Intent: Learn via retrospective chart review• Outcome: New scientific knowledge to be

generalized for adult ICU patients

• Intent: Integrate new scientific knowledge into practice

• Outcome: Fewer HAPUs

• Intent: Identify changes to achieve goal• Outcome: Reduce HAPUs on a PCU

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RESEARCH EXAMPLE

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A systematic process• What is not known:

Unavoidable Pressure Ulcers: A Causal Model (Primary Investigator: Anna K. Omery, 2010; Gretchen Summer, NCAL Primary Investigator)• Retrospective chart review• Adult ICU patients• Statistical analysis of

variables

• Descriptive, predictive, & controlled

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RESEARCH EXAMPLE

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A systematic process• Scientific knowledge via a rigorous and

systematic research process• Data• Facts• Synthesized Information• Knowledge

• Final product = New knowledge that can be generalized for adult ICU patients in the United States at risk of development HAPU

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EBP EXAMPLE

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Pre-albumin Screening to Decrease Hospital Acquired Pressure Ulcers

• KP Los Angeles Medical Center• What is known: Monitoring prealbumin levels

can be used as a screening tool to identify patients at risk for HAPU and plan nutritional interventions

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EBP EXAMPLE

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Pre-albumin Screening to Decrease Hospital Acquired Pressure Ulcers

• Systematic integration of the new knowledge into nursing practice

• Maximize patient’s nutritional regime

• Final product• Decreased HAPU• Improved QOL, decreased

pain, decreased cost, & decreased length of stay

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PI EXAMPLE

1. Analyzed baseline data = 12 in 4 months

2. Set SMART goal: PCU will reduce the number of HAPUs from average of 2 / month to no more than 1 / month by Sept 30, 2010

3. Assessed current practices and identified potential changes

• Better skin assessment skills needed – use 2 nurses• Create a tool to better assess patients at risk for HAPUs• Use Wound Ostomy Continence Nurse (WOCN) as resource• Investigated other practices/ interventions

20©Kaiser Permanente

PI EXAMPLE (CONTINUED)

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Learning about patients

actively dying

Project Start

DISCUSSION• How have you used research, evidence-

based practices, and performance improvement to improve nursing care?

• What challenges have you faced differentiating when to use research vs. performance improvement?

22©Kaiser Permanente

SUMMARY• Research and PI vary in structure,

intent, processes, outcome and data requirements

• Both have similarities:• Start with data• Conduct an analysis• Need a committed team• Rely on experts for guidance

23©Kaiser Permanente

KP IRB RESOURCES

• Standard Operating Procedures• Applications, Forms, Reports• IRB Guidance• Link: http://scalresearch.kp.org/irb/index.html

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• Nursing.Research@kp.org • http://nursingpathways.kp.org/ncal/research/nursing

researchprogram/index.html

• Gretchen.J.Summer@kp.org• http://nursingpathways.kp.org/ncal/research/nursing

researchprogram/index.html

RESEARCH RESOURCES

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Mentors Background/Training Expertise Clients / Lead IAs / Contact

Heidi Spence

Heidi is a certified as a Master Black Belt and Lean Six Sigma Black Belt.  She has15 years experience improving health care service delivery and quality.  She earned a B.S. in Cognitive Psychology and a MSW

Developing improvement capability, change management and breakthrough performance improvement with front line teams. Heidi coordinates and develops Region‐wide PI training –including Physician training, managing training requests, working with Regional wave students, etc

Northwest & Hawaii Regions, Southern California Regional Officesheidi.j.spence@kp.org :: 503.308.3848

Lynn Garofalo

Lynn has 20 years experience inhealth care improvement, and holds an BS in Finance, MHA from USC and Lean Six Sigma Black Belt  Lynn’s completing Doctor of Policy, Planning and Development from USC

Health care strategy & processimprovement, organizational change management, training, and qualitative comparative analysis

Antelope Valley: Lead IA: Jeanne RhynsburgerPanorama City: Lead IA: Sarita CohenSan Diego: Lead IA: Rudy MarillaWest Los Angeles: Lead IA: Lisa SaldanaNational Pharmacy Qualitylynn.m.garofalo@kp.org :: 310.848.4737

Maria Lee

Maria has 15 years in Performance Improvement, a PhD from MIT, an MBA from UCLA & a Master Black Belt from Motorola

Patient flow, finance/revenue cycle,lean operations, clinical & non‐clinical operations, Six Sigma, DMAIC & DFSS

Downey: Lead IA: Rhonda AlfaroLos Angeles: Lead IA: Yannis AngourasOrange County: PI Dir: Judy Kiblermaria.d.lee@kp.org :: 818.588.0687

Michael Falk

Mike has 15 years experience as a Lean Six Sigma Master Black Belt and is an ASQ Certified Reliability Engineer (CRE) with a BS in Business and a MS in Quality Assurance

Innovative process designs(scorecard and dashboard development), Quality Systems and Supply Chain improvement portfolios

Kern County: Lead IA: Victoria GraftonSouth Bay: Lead IA: Sharon WrightWoodland Hills: Lead IA: Debbie Paikosmichael.d.falk@kp.org :: 805.814.2464

Michael Mertens

Mike is certified in Lean Six Sigma MasterBlack Belt, Black Belt and Design for Six Sigma.  He has15 years experience doing improvement work in large global companies. He has a BSE in Mechanical Engineering 

He has led projects in many different areas applying Lean, Six Sigma and Design for Six Sigma methodologies

Baldwin Park: Lead IA: Dawn (Cheryl) FairbairnFontana/Ontario: Lead IA: Ahmad MohammadRiv/Moreno Valley: Lead IA: John DorothySCAL Member Services Groupmichael.a.mertens@kp.org :: 714.681.0255

SCAL PI MENTORS

CECELIA’S RABBIT HOLE

Cecelia L. Crawford, RN, DNPTranslational Research

SCAL Regional Nursing Research Program

626-405-5802Cecelia.L.Crawford@kp.org

REFERENCES

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• Albert, N. M., & Siedlecki, S. L. (2008). Developing and implementing a nursing research team in a clinical setting.

• Feinstein Institute (2009). Quality management/quality improvement (qm/qi) activities vs. research activities subject to irb review. Available at http://www.feinsteininstitute.org/Feinstein/IRB+Guidance

• Institute of Medicine (IOM) (2001). Crossing the quality chasm: A new health system for the 21st century. Committee on Quality of Health Care in America Washington, D.C.: National Academies Press.

• Omery, A. K. (1998). The process of knowledge development. Kaiser Permanente Nursing Research Series. Available at http://nursingpathways.kp.org/scal/research/resources/researchseries/index.html#supplementary

• Polit, D. & Beck, C. (2008). Nursing Research: Generating and Assessing Evidence for Nursing Practice, 8th Edition. Philadelphia: Lippincott Williams & Wilkins.

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REFERENCES

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• Titler, M., Kleiber, C., Rakel., B., et al. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13(4), 497-509.

• Titler, M. (2007). Translating research into practice. American Journal of Nursing, 107(6) Supplement, 26-33.

• Wilson, C. & Sylvanus, T. (2005). Generating enthusiasm for nursing research. Journal of Nursing Administration, 35(5), 220-222.

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REFERENCES

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• Associates in Process Improvement. (1997) The Improvement Handbook. Austin, TX.

• Brassard, M & Ritter, D (2010), The Memory Jogger. 2nd Edition. Canada.

• Langley TW, Nolan K, Nolan T, Norman C, Provost L. (1996) The improvement guide: a practical guide to enhancing organizational performance. San Francisco, CA.

• Lloyd, RC. (2004) Quality Health Care: A Guide to Developing and Using Indictors. 1st ed. Boston, MA.

• Provost, L. P., & Murray, S. (2007). The data guide: Learning from data to improve health care. Austin, TX.

• Rother, M. & Shook, J. (2003) Learning to see: value stream mapping to add value and eliminate MUDA . Cambridge, MA.

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