In Search of Best Practice
Nurses help hospitals define outcomes
By Melissa Gaskill
February 28, 2005
At the Heart Institute of CHRISTUS Spohn Hospital Corpus Christi – Shoreline, clinical nurse specialist Sherry Gilman, RN, MSN, CNS, CCRN, and her colleagues knew that patients discharged from the hospital after a cardiac event are at high risk of a second one and that the American Heart Association has identified five primary indicators that can decrease that risk. So Gilman and her colleagues collected data and evaluated the unit’s performance on those indicators.
“We looked at our practices and saw that there were three where we were about 50%,” Gilman says. “We took a multidisciplinary approach to reconstruct all that we do, involving all the different units, to actually change our practice. We wanted to be the best at this.”
To Gilman, this is an example of best practice: looking at what experts like the AHA have said, examining current practice and results, making changes and evaluating those results, and implementing changes that produce the desired outcome.
Nurses are undertaking similar efforts across the country. But while most are familiar with the term best practice, “it’s not clear that everyone means the same thing,” says Rhonda Anderson, RN, MPA, FAAN, CHE, chief operating officer at Banner Good Samaritan Medical Center in Phoenix. “People throw the term around, and there’s no consistent definition.”
At the Seton Healthcare Network in Austin, Texas, best practice means “tactics that seem to yield results better than what we find in other places,” says Joyce Batcheller, RN, MSN, CNAA, senior vice president and chief nursing executive. “You take the learning and tactics someone already has done and see if it can transfer to another area and produce similar results.”
Best practice can’t be based on opinion or anecdote, says Mary Lopez, RN, MSN, director of critical care telemetry and dialysis services at Community Regional Medical Center in Fresno, Calif. “If it isn’t measured and compared to a benchmark and you donhave consistent outcomes that improve performance, it’s not best practice,” she says. “The challenge is to measure against that benchmark and try to exceed it.”
Community Regional Medical Center, for example, tracked ventilator-associated pneumonia rates and evaluated procedures to see which ones changed outcomes.
Chuck Mercer, RN, emergency charge nurse at CHRISTUS St. Francis Cabrini in Alexandria, La., cites his department’s fax report as an example of a best practice. To admit an ED patient to the hospital, the one-page, comprehensive report is faxed, with a copy of orders, to the appropriate unit, which then has 30 minutes to admit the patient. The report decreased admitting time by 90 minutes the first week, Mercer says, and this in turn has increased patient satisfaction.
Pat McCarthy, RN, MS, manager of nursing education at the Veterans Affairs Palo Alto (Calif.) Health Care System, says a best practice depends on variables like the type of equipment used and the patient population. For instance, health care professionals consider different factors when treating geriatric patients than treating children.
Another term common these days is evidence-based practice, and nurses have different views on how the two are related.
“There is a lot of confusion and overlap with the two concepts, and they are often used interchangeably,” says Cathy Rick, RN, CNAA, FACHE, chief nursing officer for the Department of Veterans Affairs. “But there is a fine distinction between them. Evidence-based practice is research-based, grounded in scientific inquiry and evaluation. It might be used for a best practice. But a best practice may be a cutting-edge innovation that hasn’t been proved yet.”
“Evidence-based is doing what has worked in the past,” McCarthy says. “It can be the same as best practice, but not necessarily. The best practice is the outcome of the evidence.”
For example, a group of nurses at the Palo Alto VA explored the literature on taking accurate blood pressures. “We were hit with the realization that we sometimes go onto autopilot and don’t always follow the recommended steps,” McCarthy says. “We wrote up a 15-question quiz and put it in our internal newspaper for nurses to take.” The exercise led to a more evidence-based procedure.
Best practice can and should also be applied to areas outside clinical care.“It refers to the business office, the work environment, patient care, all of the above,” Batcheller says. “They are so interrelated anyway. For example, if you have a really good work environment, high morale, and good leadership, then patient care will be better because your staff will be stable.”
Anderson offers Banner’s new pediatric tower as an example. “There is work there on evidence-based design, research on design and physical features that helps achieve outcomes and im proves patient safety, engagement, and healing. We’re incorporating design features based on research.”
However you define them, evidence-based and best practices aren’t worth much unless they’re implemented. The Seton system shares practices in nursing leadership meetings and distributes information by hard copy, e-mail, the system’s nursing intranet system, and internal nursing publications.
Members of evidence-based practice committees across the VA compare notes, McCarthy says, and a practice that is proven at one facility is ultimately implemented at all. An example is a barcode medication administration system designed and tested at one hospital, expanded regionally, and finally put in place systemwide. “The internal evaluation process for that was akin to evidence-based practice,” Rick says. “Testing proved [barcoding] resulted in significant reduction in errors or poten-tial errors.”
Work teams at Banner research and test concepts for best practices, Anderson says, and like the VA, once a facility implements a practice and obtains expected results, the practice is implemented systemwide. Practices are shared on the system’s intranet and in poster sessions at company meetings. On a broader scale, clinical organizations use journals or online capabilities for sharing practice improvement and best practices.
Sharing practices is critical in an environment of health care institutions continually striving for 100% compliance or zero defects and where there’s an emphasis on budgets. Everyone is looking for tactics that make a difference, Batcheller says. “Take an idea and adopt it and see if you get the same positive outcomes. Study what is being done differently in a successful unit, then look at how you take those procedures and apply them elsewhere to get the same results.”
“Start by understanding that the provision of health care is always evolving,” Rick says. “Create that mindset of curiosity and scientific inquiry. Help staff understand that it’s okay to ask why are we doing what we are doing, to have that dialogue. Nur sing leaders have to develop the skill to do that because it isn’t always comfortable to question what you are doing. The intent is to stretch and improve.”
Best practice and Magnet status
While the concept of best practice is receiving more attention across the board, seeking Magnet status has been the catalyst for many hospitals to take a closer look.“There is absolutely a connection between best practice and seeking Magnet status,” says Rhonda Anderson, RN, MPA, FAAN, CHE, chief operating officer at Banner Good Samaritan Medical Center in Phoenix. “The inquiry that takes place within Magnet facilities is significant, and they are always striving for improvement using evidence. There’s a culture of wanting to be the best and wanting to improve and offer the best to patients and staff through evidence-based and best practices.”
There is also much sharing of practices among Magnet hospitals, says Janice Kishner, RN, MBA, MHA, chief operating officer and nurse executive at East Jefferson General Hospital in Metairie, La. “Sometimes health care has kind of a regional mindset., but there is robust sharing of information among Magnet hospitals, regardless of region.”
The Magnet Recognition Program was developed by the American Nurses Credentialing Center, a subsidiary of the American Nurses Association. The program is based on ANA’s Scope and Standards for Nurse Administrators and Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses.
The cost of attaining Magnet status can be significant and can include a $100 manual, a $2,500 application fee, expenses for appraiser site visits — with a $1,500 daily honorarium per appraiser — and internal staff and hard costs for preparing application information and documentation. Although some hospitals implement best practice, they don’t apply for Magnet status because they don’t believe they can afford it. But most hospitals see the cost as an investment.
“Anytime you look for differentiation for your facility, there is a cost involved, and Magnet status is no different,” says Anderson, whose hospital in now seeking the designation. “But there is a return as well, and I believe with Magnet, there is an enormous return. Staff seeks you out. Patients seek you out. They know you excel.”
Melissa Gaskill is a freelance writer.