ing and improvement is required to improve the likelihood that a change will be sustained. The third principle is to facilitate doing the right things. The fourth is that data need to be effectively transformed into useable and actionable information. The fifth principle is to have a clear focus for implementation. The sixth is coordination among all players, which is especially useful in complex interventions. And the seventh principle is to pilot or try the intervention prior to implementing the change systemwide.

Improving care requires a number of strategies that integrate these seven principles, and at the center of them is engaging the workforce, Titler said. Data are necessary for making care evidence based, and data should be collected not only for outcomes of care but also for the care processes that contribute to those outcomes. Data should be analyzed before, during, and following implementation of evidence-based practice changes to understand the impact of the improved care delivery.

Presenting data at the patient care unit or clinic level using statistical tools is helpful for nurse managers, and facilitates staff involvement in process improvements. Such tools include statistical process control charts, run charts, and Pareto charts. Other important strategies for improving care include listening to staff, presenting and discussing the evidence base for clinical practices such as fall prevention, and engaging unit-based change champions in process improvement and point-of-care coaching. The work of evidence-based practice improvement must be made visible through mechanisms such as internal newsletters, publications, and senior leadership reports. Interdisciplinary and interdepartmental collaboration are essential and the role of leaders is critical in engaging employees in change, Titler said. Leaders need to develop action plans to increase transparency, such as defining accountable persons, identifying an intervention’s effect on patient care, and making sure the plan for implementation is well understood. Without a leader’s vision and guidance, effective and well-planned practice improvements are unlikely to be sustained. Key questions for evaluating the success of quality improvement programs include: Have goals of the prior year been achieved? Are core metrics improving? Are people working collaboratively across departments and disciplines to improve patient care? Are staff seeking out quality improvement personnel for guidance? Challenges in improving quality of care, Titler said, include system issues such as using clinical documentation systems, competing demands by various external agencies, and using a mechanistic rather than a complex adaptive system approach. Improving systems and care processes is the role of all involved in health care.



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