Discussion Post On EBE

Discussion Post On EBE: Read the article What’s in a Name and give a brief summarize the article and include…

Discussion Post On EBE

Read the article What’s in a Name and give a brief summarize the article and include any key points you find important and interesting. 

Word count: 250 minimum – 500 maximum

References must be in APA format


Nursing & Health Sciences Research Journal

Journal homepage: https://scholarlycommons.baptisthealth.net/nhsrj/

What’s in a Name: Performance Improvement, Evidence-Based Practice, and


Andrea Prentiss & Eve Butler

Keywords: performance improvement, evidence-based practice, research

Participants of the Institute of Medicine’s

Roundtable on Evidence-based Medicine have

identified that “by the year 2020, 90 percent of clinical

decisions will be supported by accurate, timely, and up-

to-date clinical information, and will reflect best

available evidence” as a goal (Institute of Medicine,

2009). The committee felt every American should have

as an expectation, at a minimum, this level of

performance with health care delivery. Using resources

already available to them, each organization should be

able to motivate and track their progress.

One of the challenges healthcare providers have in

meeting the IOM’s 2020 goal is a difficulty

differentiating between performance improvement

(PI), evidence-based practice (EBP), and research. The

terms performance improvement, evidence-based

practice, and research are frequently used inaccurately

and interchangeably with evidence-based practice

appearing to be the most misused of the three terms.

The common goal between PI, EBP, and Research

is to provide care to patients based on scientific

evidence and meet the patient’s needs. The final result

is the same; they all should lead to improving clinical

outcomes. Determining which process to use will be

defined by what one wants to know. Questions that

seek to answer a system issue, evaluate processes of

care, or improve care delivery are addressed using

quality improvement processes. Those that focus on

how well existing science is used in care are evidence-

based processes and those generating new knowledge

about under-explored areas are answered using

research methodologies. The purpose of this article is

to review the distinction between performance

improvement, evidence-based practice, and research.


The Centers for Disease Control and Prevention

(2015) indicated that hospitals use a variety of terms to

address similar principles (i.e., continuous quality

improvement, quality improvement, performance

improvement, six sigma, and total quality

management). Performance improvement (PI) is

comprised of systematic and continuous activities that

result in measurable improvement in health care

services and the outcomes of an identified group of

patients (Health Resources and Services

Administration, 2011). Donabedian (1966) proposed

three components of health care quality when evalua-

ting the quality of health care; structure, process, and

outcome. He defined structure as the settings,

qualifications of providers, and administrative systems

through which care takes place; the organization’s

resources. Process is defined as the components of care

delivered; how the system works and specific measures

for aspects of care. Outcome is defined as recovery,

restoration of function, and survival; the final product

or outcome. (Donabedian, 1966). These concepts

remain the foundation of quality assessment today.

There are several defined methodologies used to

conduct PI projects. Our organization most commonly

uses the plan, do, check, act or PDCA cycle which is

based on Demming’s PDSA (plan, do, study, act)

Model (The W. Edwards Deming Institute®, 2016).

This is a four-step model of facilitating change usually

depicted in a circle representing no end; it should be

repeated again and again for PI and monitoring

sustainability. The Agency for Healthcare Research and

Quality (2013) defines the steps in the PDSA cycle as:


Prentiss and Butler: What’s in a Name: Performance Improvement, Evidence-Based Practic

Published by Scholarly Commons @ Baptist Health South Florida, 2018

Step 1: Plan—Plan the test or observation,

including a plan for collecting data. In order to

determine what should be done to correct the problem

you would need to identify the problem and analyze the

problem determining the root causes.

Step 2: Do—try out the test on a small scale.

Identify recommendations by the team to correct the

problem. Put the plan into action on a small scale.

Collect data and track successes or make changes to the

plan as necessary.

Step 3: Check—set aside time to analyze the data

and study the results. The question you want to ask is,

has the improvement been sustained? If not further

actions may be required.

Step 4: Act—refine the change, based on what was

learned from the test. Communicate results to

stakeholders. If changes are required repeat the PDCA

cycle until the desired results are achieved.

The following is an example of a PI question. For

patients who develop a hospital acquired pressure ulcer,

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was there consistent implementation of the skin care



There are numerous definitions of evidence-based

practice (EBP) with most of them very similar.

Evidence-based practice has been defined as “a

science-to-service model of engagement of critical

thinking to apply research-based evidence (scientific

knowledge) and practice-based evidence (art of

nursing) within the context of patient values to deliver

quality, cost-sensitive care (2014 Magnet® Applica-

tion Manual, p. 67). Apel and Self (2003) describe

evidence-based practice as the marriage of research and

clinical services. It is about translating the evidence

and using it to make patient-care decisions

(Connor,2014). The majority of the best evidence

comes from the research; however, it may come from

patient/family preferences and values, clinical

expertise, and experts in the field.

Multiple EBP models are available to guide nurses

through implementation of an evidence based practice

change including the John Hopkins Nursing Evidence-

Based Practice Model (Dearholt & Dang, 2012), the

Iowa Model (Titler et al., 2001), and the Star Model of

EBP: Knowledge Transformation (Stevens, 2012).

Baptist Health South Florida (2011) has developed its

own model to guide practice changes, Clinical

Excellence Through Evidence-Based Practice

(CETEP). This model mirrors Sackett et al. (1996) five

steps to EBP and contains the necessary components to

be considered when making a practice change (Figure


The CETEP model is comprised of five steps

which include:

Step 1: Define the clinical practice question. It is

important for nurses to formulate a searchable question

that focuses on the population of interest (P), the

intervention that you are interested in knowing more

about (I), a comparison intervention if applicable (C)

and lastly, the outcomes you hope to achieve (O).

Using PICO to guide your question development will

result in finding research applicable to your topic. An

example of a searchable question using the PICO

format is: For medical/surgical nurses (P) will

implementation of a pet visitation program (I) decrease

stress (O)?

Step 2: To assess the critical appraisal components.

Using the PICO question, the next step is to search for

and critically appraise the literature. The BHSF

medical library is a tremendous resource for nurses

wanting to make an EBP change. A request for a

literature search can be sent to the library staff using the

PICO question. Within 24-48 hours the library will

send a list of abstracts based on your PICO question.

From the abstracts you will select the most pertinent

articles and request from the library the full text article.

A systematic assessment of the research evidence is

then conducted to determine if the study is valid,

relevant to your setting, as well as what the results mean

for your population? The research then needs to be

combined to determine if they come to similar

conclusions supporting the EBP practice change. Once

the critical appraisal is completed, the next step is to

determine the applicability of the proposed practice


Nursing & Health Sciences Research Journal, Vol. 1, Iss. 1 [2018], Pg. 40-45



Figure 1

Clinical Excellence Through Evidence-based Practice


Prentiss and Butler: What’s in a Name: Performance Improvement, Evidence-Based Practic

Published by Scholarly Commons @ Baptist Health South Florida, 2018

change with the other critical appraisal components in

the CETEP Model, patient factors, and clinical setting

factors. Research evidence alone is not enough to

justify a practice change.

Step 3: Develop a plan for the EBP change. In this

step you will obtain the necessary approvals to

implement the EBP change; determine what resources

will be needed; develop and implement a communication

and education plan; and identify how the process

change will be evaluated.

Step 4: Implement the practice change. Review

the plan and verify that support and resources are

available during this step to ensure success.

Step 5: Evaluate the outcomes of the evidence-

based practice change. Using the outcome measures

identified in the planning phase, review the practice and

invite feedback. Rephrase the question as needed

repeating the steps outlined above.

The following is an example of an EBP question.

For patients who develop a hospital acquired pressure

ulcer, would implementation of a turn clock tool as

compared to a turning team be a better method in

preventing pressure ulcers during hospitalization?


Polit and Beck (2010) define nursing research as a

systematic approach to answering questions and

solving problems using a disciplined method based on

objective evidence. Its rigorous scientific inquiry

provides a significant body of knowledge to shape

health policy, advance nursing practice, and impact the

health of people across the globe (p.3). The primary

reason for conducting research is to expand the wealth

of knowledge for nursing to improve their patients care

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and outcomes. Research enhances and validates

existing knowledge as well as generating new

knowledge (Burns & Grove, 2007). The results of

research creates a strong scientific base for nursing

practice (Melnyk & Fineout-Overholt, 2014); however,

a void still exists with nursing linking research and


Florence Nightingale is usually referenced as the

first nurse researcher as result of her work in the 1850s

surrounding morbidity and mortality of soldiers during

the Crimean War. Recognizing the correlation between

the environment and patient outcomes, her work led to

improved conditions and care of sick people (UT

Health, 2017). Nursing research is fundamental to the

nursing profession and is crucial for continuing

advancements that foster optimal nursing care. It

generates new, or expands on existing, knowledge

building the scientific underpinnings for clinical

practice. Regardless of the setting a nurse works in,

the primary goal remains the same: to be a patient

advocate and provide optimal care resulting in best

outcomes (Jane, 2015).

Nursing research is usually categorized as

quantitative, qualitative, or mixed methods.

Quantitative focuses on measurable outcomes, usually

analyzed with statistics whereas qualitative is based on

phenomenology or ethnography focusing on

experiences and analyzed with words. Research starts,

as all three processes do, with the identification of a

problem or question; what is it you want to know. One

then needs to determine the research goals, identify

what will be done, the methodology to conduct the

research, and then evaluating the results.

Developing the research question begins with an

idea, what is being questioned. This is also, as in EBP,

phrased using the PICO acronym. The research

question may be refined following the literature review

but the development of the PICO question ensures the

key words are present to help with the needed literature

review. A thorough literature review then needs to be

conducted in order to determine the existing knowledge

surrounding the topic, a gap in the literature, narrow the

research question, and determine the type of study to be

completed. Occasionally a study can be found that is

very similar to the one desired; it is perfectly acceptable

to replicate a study.

A quantitative study should have a research aim or

purpose, a hypothesis, independent and dependent

variables, instruments or scales to measure the

variables, and identified sample size, protection of

human subjects, and statistical analysis. Qualitative

studies involve similar steps but the data collection is

usually performed through interviews and

observations. There are four overarching types of

quantitative research: experimental, quasi-experimental,

descriptive, and correlational. Qualitative research,

focused on understanding the human experience, has

five main types of designs: phenomenology,

ethnography, grounded theory, historical method, and

case studies (Hunt, 2017). A conceptual framework or

theoretical model should be identified to help guide the

research process; these determine what you will

measure and the statistical relationships.

Included in the study methodology is the study

design, the sampling strategy, and data collection and

analysis. The research process includes a protocol and

application for Institutional Review Board approval.

The entire research process should be developed with

the entity nurse scientist.

The following is an example of a research

question. For patients who develop a hospital acquired

pressure ulcer, would implementation of a pressure

ulcer prevention bundle that includes patient


Nursing & Health Sciences Research Journal, Vol. 1, Iss. 1 [2018], Pg. 40-45


participation, decrease the incidence of pressure ulcers

in hospitalized patients?


In summary, PI is a formal approach to the analysis

of performance, unit based or entire hospital or system.

It is driven by data. It classically assumes that the

appropriate therapy or care is known but deviations

from the know standard has occurred and needs to be

identified and corrected. Changes are made in a

systematic manner, measuring and accessing the effects

of change, feeding the information back into the

clinical setting, and making adjustments until

successful results are obtained. The process is

continual, cyclical, in order to ensure positive achieved

outcomes continue.

Evidence-based practice is widely accepted by all

healthcare personnel desiring to base their care on

current evidence. Nurses are expected to have the

ability to develop, implement, and evaluate evidence.

Although the evidence-based practice model may

differ, the guidelines for use are similar: synthesis of

the evidence, consideration of where and how the

evidence is being implemented, and evaluation of the


Research, the most rigorous of the three methods,

is a systematic approach to answering questions. It is a

disciplined method for solving problems based on

objective evidence and is designed to contribute to

generalizable knowledge. Institutional Review Board

approval must be granted before conducting the study.

Table 1 provides an overview of the differences


between performance improvement, evidence-based

practice, and research. Baptist Health South Florida is

fortunate to have many resources to assist those

attempting to understand and work with these three

processes. Library services will facilitate the literature

search obtaining abstracts and full articles upon

request. Additionally, each entity has a nurse scientist

who can also help differentiate what the project entails

and how to conduct it. Dissemination is the final step

in whichever process is conducted, whether at the unit

level or through a larger venue.


Table 1

Differences between PI, EBP, and Research

PI EBP Research

Purpose Improve patient care practices Change practice Generate new knowledge

Method PDCA



Articles: Qualitative and


Expert opinion







Sample Unit or organization Related to identified


Related to purpose and

research question


Data collection Short term

Action plan & evaluation

Critical appraisal of articles

Searching for best evidence

Ensure external and

internal validity,


Long term

Human Subjects No IRB unless sharing

information externally

Assess IRB process

described in article


Results Seeks to improve processes in

unit and organization

Seeks to impact practice Seeks to add new


Implications Change processes

Decrease cost

Increase efficacy

Increase patient and staff


Improve satisfaction

Use of research to impact



understanding of issues in

a phenomenon


Prentiss and Butler: What’s in a Name: Performance Improvement, Evidence-Based Practic

Published by Scholarly Commons @ Baptist Health South Florida, 2018


The authors report no conflicts of interest. The

authors alone are responsible for the content and

writing of the paper.


Andrea Prentiss, PhD, MSN, ARNP, CNS, Nurse

Scientist, Baptist Hospital of Miami, Miami, FL, US.

Correspondence regarding this paper can be directed at


Eve Buttler, PhD, RN, Nurse Scientist, Baptist

Hospital of Miami, Miami, FL, US.


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