Leadership Commitments to Improve Value in Health Care Finding Common Ground: Workshop Summary (2009) / Chapter Skim
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6 Healthcare Professionals
6 Healthcare Professionals
Pages 117-148
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From page 117... ...
has been defined as "the integration of individual clinical expertise and patient preferences and values with the best available external clinical evidence from systematic research" (Sackett et al., 2000)
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The focus is on the delineation of strategies that will shift healthcare delivery away from the traditional physician-dominated practice and toward a concept of practice performed by interdisciplinary teams empowered to seek out and implement the best evidence for patient care. Such teams will have both the ability and expectation to continuously learn and change, through informed access to evidence-based clinical decision support, informatics, and clinical data repositories.
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From page 119... ...
What is less well known but what can perhaps be inferred from data on behavior is how physicians perceive the technologies that are relevant to the implementation of EBM, that is, whether they perceive them to be important to their efforts to improve patient care. Clearly, one must be concerned that the slow adoption of healthcare IT -- and the push back that has been apparent among leaders in the healthcare professions regarding efforts to promote quality measurement and industrial approaches to quality improvement based on that measurement -- reflects a prevalent attitude that the adoption of healthcare IT is not necessarily in the best interests of patient care (Audet et al., 2005)
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. As an intrinsic part of medical education, training in EBM provides individual physicians with critical search and appraisal skills for review of the medical literature, introduces the concept of continuous quality assessment as a routine of medical practice, and provides the basis for effective lifelong learning directly linked to patient care.
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Achievement of the last competency explicitly requires exposure to "investigation and evaluation of patient care practices, appraisal and assimilation of scientific evidence, and continuous improvement of patient care practices." There is a timeline for implementation of this new approach to resident education: at this time, all residency training programs must have begun to provide learning opportunities in the six defined competency domains, with the requirement for full integration of the training in the competencies and their assessment by June 2011 (ACGME, 1999)
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A variety of computer-based clinical decision support systems have been shown to improve clinician performance and patient outcomes (Hunt et al., 1998; Kuperman et al., 1996) and to specifically increase the rate of use of evidence-based guidelines (Dexter et al., 2001)
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are educated through master's degree and clinical doctoral programs, whereas nurse researchers are educated in doctor of philosophy and nursing science doctoral programs that place an emphasis on the learning of the knowledge and skills required to conduct rigorous studies that extend science and produce evidence to guide best clinical practices. Nurses assume vital roles in the healthcare system, such as (1)
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the omission of EBP as a responsibility and a lack of accountability in clinical practice (Fineout-Overholt et al., 2005; Melnyk and Fineout-Overholt, 2005; Pagoto et al., 2007)
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. Research in nursing academic programs has also traditionally been taught in isolation and not as part of other nursing courses, and thus, students have failed to see the application of research findings to clinical practice (Burke et al., 2005)
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Leaders within healthcare organizations (e.g., chief medical and nursing officers) , with the input of interdisciplinary healthcare professionals, need to create an exciting vision and strategic plan for EBP, as well as provide the culture and necessary resources to support it (Melnyk and FineoutOverholt, 2005)
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. Therefore, to advance EBP, healthcare systems should implement educational and fellowship programs to enhance the EBP-related knowledge, beliefs, and skills of its staff; provide EBP mentors who can work directly with staff to implement EBP initiatives, such as journal clubs and EBP implementation/ outcomes management projects; and provide the necessary administrative support and resources, including computers for the use of EBP at the point of care and healthcare IT systems that are user friendly.
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From page 128... ...
Thus, it has been a challenge for the profession to implement the services described above more broadly without a payment model for drug therapy management or patient care. Clearly, with the extensive shift to patient-focused services, there is a greater need for pharmacists to use an evidence-based approach to clinical decision making.
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to improve patient care is often suboptimal. The literature contains many examples of high-quality systematic reviews, evidence-based guidelines, and so forth that could be used to recommend best practices; however, the implementation and adoption of these practices fail to achieve the desired goals.
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For years, pharmacists have received extensive training in drug information as well as appraisal of the literature; and the most recent accreditation standards (July 2007) , set forth by the Accreditation Council on Pharmacy Education, explicitly highlight the need to incorporate EBP, quality improvement, and informatics into the professional pharmacy education curriculum (Accreditation Council for Pharmacy Education, 2006)
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. Graduate Programs and Postdoctoral Fellowship Training Postdoctoral fellowship training programs, master's degree programs, and doctoral programs in pharmacy emphasize the research skills needed for drug discovery, product development, the translation of basic science into clinical practice, health services research, and postmarketing surveillance research.
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; a lack of administrative and institutional support; insufficient time; a perceived lack of evidence; a lack of relevant patient data; and logistical issues, including a lack of resources to effectively retrieve high-quality evidence or a lack of infrastructure to support EBP (Pagoto et al., 2007)
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ACTIVITY CATEGORIES Cultural Change and Education The primary shift to EBP will require its integration into the curriculum throughout the following areas of formal education of all future healthcare professionals: core education, in partnership with medical schools and the Ameri • can Association of Medical Colleges, nursing schools, pharmacy schools, and so forth; postgraduate training programs and internships, in partnership • with academic medical centers and ACGME, plus residency review committees, nursing and pharmacy schools, and so forth; and required competency, in partnership with licensing organizations, • including the National Board of Medical Examiners, specialty and subspecialty certification boards, and state licensing boards; the National League for Nursing Accrediting Commission; the Com mission on Collegiate Nursing Education; and the National Council of State Boards of Nursing. A multifaceted approach to the education of practicing healthcare professionals to promote the universal adoption of EBP will require
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Changes to the healthcare culture are essential to support EBP. • To involve healthcare professionals in routine EBP, universal rapid • access to medical knowledge and clinical practice guideline reposi tories in all clinical practice settings is necessary.
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Preclinical evidence-based review methodology, • principles of epidemiology, • explicit training in searching the literature and evaluating the evi • dence found, training in database interrogation, and • training in the basics of clinical research. • Clinical the concepts of quality measurement and improvement through • the use of routine patient data and through audits and reviews of practice results, as illustrated routinely during clinical rotations; continuous access to medical knowledge and clinical guideline • repositories; modeling of evidence-based decision making by faculty with knowl • edge and experience in EBP; this will often require faculty to have training and experience in EBP; exposure to innovative cross-disciplinary curriculums that train • integrated teams of healthcare professional faculty and students; routine exposures to interdisciplinary team care; this will require • integration with other healthcare professionals; the concept of continuous learning, which should be explicit in • the curriculum and implicit in clinical rotations, as modeled by faculty;
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In addition, healthcare professional students should be assessed for their competence in preventive medicine and evidence-based knowledge and decision making before they graduate. Proposed Initiatives in Graduate Clinical Education As part of their graduate clinical education, students should routinely be exposed to interdisciplinary healthcare teams that use evidence-based methods to deliver care.
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• Provide oversight by - requiring licensure standards to include knowledge of EBM; - assessing a healthcare professional's knowledge of EBM in specialty and subspecialty board examinations as a component of the initial certification and the maintenance of certification; and - including specific training in EBM and reporting of EBM as a performance standard for licensure and maintenance of certification. Proposed Initiatives in Practice Setting Systems Change Table 6-1 provides examples of some of the initiatives already in place in the clinical practice setting.
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a 17-credit online distance education workshops graduate/post-master's degree certificate in EBP plus week-long EBP multidisciplinary immersion workshops for healthcare professionals. CME and Inclusion of MD The American Board of Internal Medicine regulatory physician- Physician Consortium for Performance oversight specific EBM Improvement has developed three different training and practice assessment options.
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- Involve practicing healthcare professionals in the development of research questions with direct clinical practice. - Provide specific opportunities for solo and small group prac tice and community hospital settings to participate in clinical practice research networks.
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Support EMR development to allow inquiries of the patient data • base for clinical research. Collaboration of Healthcare Professionals Sector with Other Sectors Clinical Investigators Interact to expand the clinical base from which evidence is gener • ated to include a wide range of practice settings and observational data.
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NEXT STEPS The adoption of EBP, including the shift to patient-centric care, will require nothing short of a transformation of current medical practice. In this transformation, healthcare professionals can be described as the critical transition point between current healthcare practice and the delivery of evidence-based care.
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Proposed members could come from among the following groups: ACGME; American Academy of Nursing; American Association of Medical Colleges, including the Council of Deans; American Boards of Internal Medicine, Pediatrics, Family Practice, Surgery, and so forth; Commission on Collegiate Nursing Education; National Council of State Boards of Nursing; National League for Nursing; National Organization of Nurse Practitioner Faculties; and professional societies such as the American Academy of Pediatrics, American Association of Colleges of Nursing American College of Cardiology, American College of Pharmacy, American College of Surgeons, and Society of Thoracic Surgeons. IT developers, health practitioners, and leaders from the whole range of healthcare settings and professional organizations would be charged with working together on the design and development of support for EBP, including the development of a culture that supports EBP.
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Finally, appointment of an EMB Interdisciplinary Healthcare Professionals Advisory Panel is recommended as the critical first step in providing sustained leadership for initiation of the process needed to maximize the adoption of EBM in clinical practice. REFERENCES Accreditation Council for Pharmacy Education.
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In Evidence-based nursing. A guide to clinical practice, edited by A
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1998. Effects of computer-based clinical decision support systems on physician performance and patient outcomes: A systematic review.
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Barnes. 2007 Advancing research and clinical practice through close collaboration (ARCC)
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. National Board of Medical Examiners.
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2006. Quality improvement strategies for hypertension management: A systematic review.
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