November 20, 2022

Through your reading of Chapter 19 and the recorded lecture, you have learned about using evidence to influence organizations and policy. Script then record an elevator speech to either a

Through your reading of Chapter 19 and the recorded lecture, you have learned about using evidence to influence organizations and policy. Script then record an elevator speech to either a Chief Nursing Officer or policy maker based on pressure ulcers/injuries evidence from the clinical practice guideline, Dr. Brindle’s lecture and High Tide Health data.

Chapter 19

Using Evidence to Influence Health and Organizational

Policy

Chapter 19

Using Evidence to Influence Health and Organizational

Policy

Defining “Policy”

“Policy” is used to describe both the entity and the process.

As an entity—policy is a tangible result (a law or municipal code) or other governmental process that includes:

• Judicial decrees

• Position statements

• Resolutions

• Budget priorities

Other kinds of broad “health policies” are:

• Published by nongovernmental organizations

• These have impact on health policy

Defining “Policy”—(cont.)

As a process—it’s the series of actions and activities taken to bring a problem to the attention of government actors who work to address the problem.

When policy refers to “health policy,” these actions are often thought of as those targeting improvements for the health of populations.

Challenges Unique to the Relationship Between Evidence and Health Policy

Policy making is:

• Nonlinear

• Influenced by social and political factors such as:

– Partisanship

– Diverse stakeholder values

– Public opinion

– Media coverage

– Timing of congressional and legislative cycles

– Budget restraints

– Strategy and skill of players

Using Evidence: Clinical Practice vs. Policy

In clinical practice:

• Cultures and organizational structures more apt to press for practice based on evidence

In political environments:

• Pressing for policy based on evidence can have less favorable outcomes.

• Terminology in policy is “evidence-informed” policy rather than “evidence-based” policy.

• Goal: use evidence to inform, influence, or mediate dialogue between policy makers and stakeholders.

Question

Which of the following statements is false?

A. “Evidence-based” policy is the current term for using evidence to inform health policy.

B. “Policy” refers to both an entity and a process.

C. “Health policy” refers to both laws that impact population health and healthcare organization policy.

D. Nuances in clinical practice are different from nuances in the health policy world, making strategies to use evidence to drive policy different.

Answer

A. “Evidence-based” policy is the current term for using evidence to inform health policy.

Rationale: “Evidence-informed” policy is the current term for using evidence to inform health policy. “Policy” refers to both an entity and a process. “Health policy” refers to both laws that impact population health and healthcare organization policy. Nuances in clinical practice are different from nuances in the health policy world, making strategies to use evidence to drive policy different.

Evidence-Informed Health Policy Model (EIHP)

• Policy makers are more likely to respond positively to evidence when it is presented in a way that is:

– Compelling

– Understandable

– Conveyed in the context of citizen/constituent needs

The Evidence-informed Health Policy Model is adapted from the Melnyk & Fineout-Overholt Seven Steps of EBP.

Comparison of EBP and Evidence-Informed health Policy Components

Preparing Evidence for Dissemination to Policy Makers

Multiple opportunities exist to disseminate evidence in Evidence-Informed Health Policy (EIHP):

• During Step 4 (when best evidence is integrated with issue expertise and stakeholder values and ethics).

– Most likely to happen in “behind-the-scenes” negotiations/planning or task force meetings with bill sponsors or regulatory staff

• During Step 6: Policy change is framed for appropriate dissemination to affected parties.

• During Step 7: Effectiveness of policy change is evaluated and findings disseminated.

Preparing Evidence for Dissemination to Policy Makers—(cont.)

Multiple methods used to disseminate (or communicate) evidence to policy makers.

Informal methods include:

1. “Elevator speech”

2. Policy brief—typically consists of bulleted talking points

• Both are brief

• Used as one-way communication method

Formal method includes:

3. Providing testimony during a hearing

Dos and Don’ts of Using Evidence During Testimony

DO:

• Analyze the policy-maker “audience” (lawmakers or regulators?)

• Know committee membership (chair, minority leader, etc.)

• Address how the body of evidence is relevant

• Use examples from your own clinical expertise to bridge the evidence-to-practice reality

• Respond professionally to questions

• Include a reference page as an appendix to your testimony with URL links

Dos and Don’ts of Using Evidence During Testimony—(cont.)

DON’T:

• Use medical jargon or research terms

• Cite individual research studies—focus on the relevant BODY of evidence

• Get to the point

• Become defensive or emotional during testimony delivery or questioning

• Express evidence in a way that could be misinterpreted as a “turf battle”

• Respond to a question you don’t know the answer to with a simple “I don’t know.” Instead, say “That’s a great question. I will be happy to find out and get back to you.”

Question

Which of the following is appropriate behavior when testifying on a policy issue?

A. If you don’t know the answer to a question, simply state, “I don’t know.”

B. Use examples from your own clinical expertise to bridge the evidence-to-practice reality.

C. Be very detailed in your description of the body of evidence.

D. Cite individual research studies.

Answer

B. Use examples from your own clinical expertise to bridge the evidence-to-practice reality.

Rationale: Using examples from your own clinical expertise to bridge the evidence-to-practice reality, making the issue more “real.” Don’t

• State “I don’t know” If you don’t know the answer to a question.

• Give a lot of detail in your description of the body of evidence; get to the point.

• Cite individual research studies. Instead, discuss the BODY of evidence.

Using Evidence to Influence Organizational Policy

EBP should be the foundation for all organizational policy

The EBP competencies:

• Help organizations establish expectations for clinicians

• Develop mechanisms to build EBP knowledge and skill

• Measure achievement of each competency

• Hold clinicians accountable to this professional expectation

EBP is an effective strategy to contribute to improved care through utilization of best evidence to drive organizational policy decisions.

Successful Policy Committee Structures and Processes

• Committee infrastructure: charter, checklists, and membership

– Put structures in place to:

• Identify purpose and processes

• Assure representation of all departments who will be impacted by the policies

• Policy committee leadership

– Need visible, tangible committee leadership

– Responsibilities include

• Engagement of committee members

• Promoting and sustaining an effective EBP culture

Competency assessment for policy committees

• EBP competencies set expectation for committee member expertise.

• Engage EBP experts from within and outside the organization to provide needed EBP education.

Operationalizing a collaborative interprofessional policy committee

• Creating an interprofessional collaborative provides a platform to foster interprofessional collaboration and engagement.

Successful Policy Committee Structures and Processes—(cont.)

Challenges and Change Management

Time: Anticipate need to review policies every 3 years

• Anticipate time needed to engage in EBP to support sound policy creation/review

– Time to search databases

– Time to appraise and synthesize literature

Committee member variation in skill and confidence

• Engage EBP experts to provide needed education.

• Engage EBP mentors to provide support/guidance.

Changes in committee membership

Question

Which of the following is NOT a consideration when applying EBP to organizational policy?

A. The EBP expertise of policy committee members

B. The time needed to manage utilization of EBP to guide organizational policy review

C. Appointing a strong lead for the policy review committee; preferably a physician

D. Utilizing EBP experts and mentors to provide needed education

Answer

C. Appointing a strong lead for the policy review committee; preferably a physician

Rationale: Appointing a strong lead for the policy review committee, preferably a physician, is not a consideration. Any leader who is able to navigate the challenges of leading an interprofessional committee is appropriate. Other considerations to keep in mind when utilizing EBP to organizational policy include assessing the EBP expertise of committee membership, planning for the time needed to manage utilization of EBP to guide organizational policy review, and utilizing EBP experts and mentors to provide needed education to committee members.

Slide 1
Defining “Policy”
Defining “Policy”—(cont.)
Slide 4
Using Evidence: Clinical Practice vs. Policy
Question
Answer
Evidence-Informed Health Policy Model (EIHP)
Slide 9
Preparing Evidence for Dissemination to Policy Makers
Preparing Evidence for Dissemination to Policy Makers—(cont.)
Dos and Don’ts of Using Evidence During Testimony
Dos and Don’ts of Using Evidence During Testimony—(cont.)
Question
Answer
Using Evidence to Influence Organizational Policy
Successful Policy Committee Structures and Processes
Slide 18
Challenges and Change Management
Question
Answer

IN TR ODUCTION

MEET TH E PATIEN TS

VISIT TH E UN ITS

High Tide Health System Medical Center

Magnet Journey

Case Studies

Emergency Department

Orthopedic Unit

Operating Room

Surgical Trauma ICU

High Tide Health System Pressure Ulcer Case

Neuroscience Unit

Summary

High Tide Health System Medical Center

The HTHS Medical Center, a 400-bed inpatient facility with a Level 2 trauma center

designation, is part of the High Tide Health System. It opened in 1974 as a result of a

partnership between Oceanfront Hospital and High Tide University. It is located in an urban

setting with a largely indigent population.

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High Tide Health System Medical Center

 Visit the HTHS website to learn more about the Health System and Medical Center.

Website password: ceomast

https://www.hightidehealth.org/

C O NT I NU E

High Tide has not previously been a Magnet designated facility, but the organization is

optimistic that its outstanding nursing engagement and positive patient outcomes will help

them achieve this recognition.

Pressure Injury Prevalence

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Magnet Journey

The hospital environment is especially energized

at this time, as team members on the recently

implemented Magnet Team are hard at work on

their Magnet document that will be ready for

submission in the upcoming quarter.

One requirement to become a Magnet designated facility is to report a pressure injury

prevalence rate quarterly. Fortunately, High Tide is currently performing a quarterly

prevalence study. The quarterly prevalence rate falls below the national benchmark of 2.5%,

but the organization has been unable to consistently meet the internal stretch target of 1.5%.

Often times there is a signi�cant rise in prevalence in between quarters for an unknown

reason.

Members of High Tide Medical Center's Magnet Team review wound care data

The stretch target of 1.5% was proposed by the Wound Care Team in 2017 as a measurable

and attainable goal for hospital acquired pressure injury (HAPI) prevalence when the

organization was tasked with reducing hospital acquired pressure injuries by its hospital

board. The stretch target was selected by analyzing and comparing High Tide’s performance

against other academic medical centers. The organization has been given one year to make a

positive and consistent change.

Assessment and Education

Currently, the Wound Care Team at High Tide assesses patients with pressure injuries and

makes recommendations for care. They provide prevention education for newly hired nurses.

They also collect data for the quarterly pressure injury prevalence study. This is a time

consuming task for the small Wound Care Team of 5 Wound and Ostomy certi�ed nurses.

The team has often considered utilizing the knowledge and skills of bedside nursing sta� to

help collect this data. Additionally, the team has exploring strategies to change the culture

from treatment to prevention. It is to the bene�t of the patients and the organization to be

proactive rather than reactive.

Magnet Document Contribution

The Wound Care Team has contributed to the Magnet document with its work in wound and

ostomy care. At a recent team meeting, a Wound Care Team member acknowledged that a

great deal of work for the Magnet document was created in collaboration with varying levels

of leadership and bedside sta�. The Wound Care Team consulted with the Magnet team to

discuss how leadership support can be obtained and how the framework utilized for the

Magnet document can be used to successfully implement a comprehensive pressure injury

prevention program. The framework includes the following domains:

Transformational Leadership

Structural Empowerment

Exemplary Professional Practice

New Knowledge, Innovation, and Improvement

It was also discussed at the team meeting that the culture among bedside sta� can often

re�ect skepticism of new processes. While bedside sta� at High Tide is highly engaged, they

often feel overwhelmed with growing expectations from the organization. Many team

members in the environment are aware that hospitals do not receive reimbursement for the

care of hospital acquired pressure injuries, but not all realize this is about more than money

or “checking a box” to meet a standard. Instead, it is about taking excellent care of the

patients. As a result, the Wound Care Team posed the following question:

It appears that most of the hospital acquired pressure

injuries occur in the ICU and a large portion of these

injuries are caused by medical devices. This is useful

information when planning pressure injury prevention

education.

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How can we convince team members that this is not just about money or numbers, rather, it’s about providing the best possible care and preventing harm among our patients?

Scene 1 Slide 2

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The Wound Care Team has previously met with leaders on the inpatient units to identify

barriers to prevention and to communicate the goal of decreasing the hospital acquired

pressure injuries, but the team is at times met with resistance. Recent feedback has included

as shown below:

“The organization is already doing what can be done to decrease pressure

injuries.”

– Valerie Sowards

“Units are already tasked with so many other key initiatives”

– Danny Coyle

“We do not have the sta� or the resources to achieve the goal of 1.5% HAPI

prevalence.”

– Kelly Herrmann

The Wound Care Team recognizes that additional resources are needed for sta�ng,

education, and implementation of best practice guidelines in order for the comprehensive

program to be successful.

C O NT I NU E

In order to identify opportunities for improvement and determine root cause analysis, the

Wound Care Team pulled the list of patients who sustained a hospital acquired pressure injury

in July 2019. This month was selected as this was the highest HAPI prevalence month in

2019. Of the 17 patients with hospital acquired pressure injuries, 5 were selected for review.

Additionally, two cases in which the patient was hospitalized for >100 days but sustained no

pressure injuries were also selected for review. This could provide the team with information

as to what processes were in place to promote positive outcomes.

View the 7 cases below:

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Case Studies

Case Study 1 –

UNIT: MEDICAL RESPIRATORY ICU 51 YO Caucasian male, 86.4 kg, with Hx of: Dysphagia, Malnutrition, MRSA, COPD, DM, Aortoiliac disease, HTN, ESRD Pt in ICU for 115 days. NO evidence of pressure injury throughout stay. What went well?

Pt was on the right surface

Pt was turned and repositioned appropriately

Nursing sta� aware of high risk for skin injury status (discussed as a team in daily huddle)

Appropriate prophylactic dressings were utilized

Pt’s family educated appropriately and engaged in patient’s care

Case Study 2 –

UNIT: NEUROSCIENCE 81 YO African American male, 112.2 kg, with Hx of: HTN, HLD, DM, CHF, CAD, CVA In ICU for 185 days, no evidence of a pressure injury throughout stay. What went well?

Pt was on the right surface

Pt was turned and repositioned appropriately

Nursing sta� aware of high risk for skin injury status (discussed as a team in daily huddle)

Appropriate prophylactic dressings utilized

Family not present, but verbalized concern about patient’s skin on multiple occasions via telephone conference. This created a stressful environment for the bedside sta�, but it required them to be diligent with turning/repositioning and thorough skin assessment.

Case Study 3 –

UNIT ASSOCIATION: SURGICAL TRAUMA ICU 32 YO Caucasian male, 207 kg, with Hx of: HTN, Malnutrition, Obesity, Mental Illness, Multisystem organ failure, sepsis, use of vasopressors to maintain blood pressure. Pt hospitalized for signi�cant injuries s/p MVC. Pt was incontinent of stool and had Foley catheter in place. Pt on bedrest. Pt sustained Stage 4 pressure injury to sacrum, unstageable pressure injury to occiput (due to C-Collar), and unstageable pressure injury to anterior neck (due to trach plate). When providing an explanation for the cause of the injury, nurses on the Surgical Trauma ICU noted that the Bariatric patient that was di�cult to turn and o�oad appropriately. The C- Collar utilized was the incorrect size for this patient. The trach plate was sutured tightly in place for 17 days and was not properly o�oaded.

Case Study 4 –

UNIT ASSOCIATION: EMERGENCY DEPARTMENT 62 YO African American female, 219 kg, with Hx of: HTN, DM, Obesity, Asthma, COPD, Tobacco use Pt arrived to ED c/o dyspnea and fever. Pt in ED for 21 hours awaiting room for admission. Pt laid on hospital stretcher for 21 hours prior to being transferred to hospital bed in room. While in the ED, the pt had requested that the head of the bed be elevated to at least 60 degrees due to SOB. Pt reports sleeping on multiple pillows at home to assist with her breathing. Pt had multiple episodes of urine incontinence while in the ED. Sta� in the ED were not always available to clean the patient’s skin after each episode of incontinence, so the patient’s skin and sheets were frequently soiled with urine for long periods of time. Pt found to have signi�cant pressure injuries to her sacrum and bilateral ischium 3 days into admission.

Case Study 5 –

UNIT ASSOCIATION: ORTHOPEDICS 72 YO Caucasian male, 76 kg, with Hx of: Asthma, CAD, DVT, HTN, Osteoarthritis Pt underwent L hip replacement due to osteoarthritis. Pt’s mobility limited during admission. Per physician order: Weight bearing 25% LLE. ROM: Flexion and extension only. Dilaudid for pain. Pt had requested Dilaudid frequently for pain. This contributed to his lethargy and his failure to reposition self in bed. Review of the documentation revealed that the pt’s left heel was placed in a heel protector boot. The RLE was not elevated and the right heel was not �oated. As a result, the patient developed a deep tissue injury to the right heel. Upon questioning of the nurses, they stated they believed the patient was repositioning himself since he was mobile prior to surgery.

Case Study 6 –

UNIT ASSOCIATION: OPERATING ROOM 18 YO African American male, 63 kg, with Hx of: metastatic sarcoma, anxiety. Pt underwent abdominal surgery and was in OR for 22 hours. Pt was placed on a gel overlay during surgery. Pt had a gel donut pillow placed under head during surgery. OR nurse charted post-operative skin assessment consistent with pre-operative skin assessment. Pt not turned in PACU due to signi�cant abdominal pain. Pt was transferred back to ICU 3 hours after completion of surgery. Three days after surgery, pt found to have circular deep tissue injury to his occiput and a deep tissue injury to his right heel.

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Through your reading of Chapter 19 and the recorded lecture, you have learned about using evidence to influence organizations and policy. Script then record an elevator speech to either a

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