Rethinking EBP

"Evidence-based practice" and "best practices" are lionized as the key to improvement of more or less everything. To an extent, that claim has tremendous validity. There is also a Dark Side.

As an evidence-based practice fellow, I've discovered that if the question is at all complex, figuring out "what the evidence says we should do" is a labyrinthine process that can lead to no real answers. What does the evidence say? Who decides? In my effort to determine the best evidence-supported strategies for preventing patient falls, some of the most scholarly of the research demonstrated the most glaring misunderstandings of such concepts as "risk factors" and the conditions needed to truly test the "specificity" of a tool.
"Best practices" have a similar shortcoming. Often, such practices are "best" only in proscribed circumstances, which may or may not have anything to do with the problem you're trying to solve or the process you're trying to improve.
Both approaches are also time-consuming, whether they yield useful results or not. In the increasingly dynamic environment all industries (including health care) find themselves, is the expenditure of limited resources in such endeavors an investment, or merely a gamble? Is there another way?

Perhaps instead of chasing the horizon or falling into perfectionistic paralysis trying to identify "best practices," we can make faster progress seeking and implementing better practices:

• Is there something, however small, you could be doing better?
• Does an alternative have research supporting it, or at least make prima facie sense (sometimes, that's as good as it gets)?
• Instead of sweeping, large scale changes, can changes be made incrementally?
• Is there a story that supports the change?

This last item is important: there must be a compelling story for a change to be supported and new patterns established. Data and facts do not change minds, the truth doesn't speak for itself, nor does it set you free. There needs to be an emotionally engaging story to sell the change, no matter how much research supports it.

Evidence-based best practices have a well-earned place among quality improvement techniques. However, progress and improvement can also be impeded by the perfectionistic pursuit of that one best practice, or endlessly delayed while evidence is gathered and analyzed, by which time there is new evidence to be considered. Identifying and implementing "better practices" may better allow progress to be pursued with agility and alacrity.

Loved to Death

There is currently a lot of debate around how or even if manufacturing processes such as LEAN and Six Sigma "have any place in health care." The question seems polarizing, with both opponents and proponents providing more heat than light. As if global warming isn't bad enough already.
The problem isn't so much a particular technique (or dare I say, fashion), it is the managerial propensity for falling in love. It's happened before.
Remember clinical paths (care maps, critical paths)? They were going to be the saviour of health care! For a while, they showed some promising results. Patients got better and more timely care. Outcomes improved. Across-the-board job satisfaction of health care workers improved. The costs of providing care decreased.
So what went wrong?
One of the truths about any tool is that it works well for a specific and proscribed number of tasks. This is as true for clinical paths as it is for screwdrivers. You might be able to adjust a Philips-headed screw with a flat-blade screwdriver, but using a Philips screwdriver would yield better results and be easier.
Similarly, clinical paths worked beautifully for some specific diagnostic or procedural group: open-heart surgery, joint replacement surgery, treatment of community acquired-pneumonia. Steps that improved patient outcomes were identified, and systems were put in place so they weren't missed. Activities that did not improve outcomes were minimized or deleted outright. Costs went down and patients got better faster and everyone was happier.
Then someone decided that if it worked for these groups, we should do it for everyone! My standard screwdriver drives standard screws so well, let's use it to drive other screws! And drive nails! And saw wood! And (this is critical) think of the money we'll save!
That the proposition made no sense whatsoever was somehow overlooked.
You can imagine what happened. Clinical paths work, and work well, for those patients who are likely to have a fairly standard hospital course. If the diagnosis, patient response, or complications make the course in any way non-standard, the patient "falls off the path." This isn't necessarily bad, but the tool is no longer useful, and all the improvisation or wishful thinking or watering down will make it so. When one hospital I worked at announced the goal of having 90% of the patients on clinical paths, I knew they were doomed. Some of the paths became so generic that it met the stated goal, but did nothing to improve patient care. Make that "less than nothing": it diluted the power of a once-useful tool, created a paperwork distraction from the real work of patient care, and created the false dichotomy of "it's either useful for everyone, or it's useless."
No tool is useful for everyone, in all circumstances, ever. So instead of using clinical paths only where they were designed to work, they were used everywhere, then abandoned in frustration when the earlier results weren't replicated.
I don't know much about LEAN or Six Sigma. I've heard accounts of it working well in some aspects of health care delivery, and disastrously in others. Even at Toyota, when LEAN was first popularized, the technique was over-applied with horrendous consequences.
I don't believe these techniques will save health care. I don't believe they will necessarily destroy it, either. They, like other tools, will have their appropriate place where they will produce remarkable improvements in quality, cost control, and value.
Then, if the pattern holds true, someone will fall in love, apply the principles where they don't work, and ruin everything. How do we keep that from happening again?
I'm not sure. I think a reasonable start is to learn these systems for ourselves, so that we fully understand their appropriate uses. We also need a healthy level of skepticism: no bullet is magic. Any approach in current favor should be critically appraised with at least this question: "What circumstances or processes do this technique's developers recommend it not be used for?" That question should have a meaningful answer, and that answer should be believed.
We all need to be willing to try new tools, as there may well be something better out there. We also need to understand those tools, understand their appropriate use, and use them correctly.
It's something we aren't particularly good at.

Defining "Safe"

As members of the Minnesota Nurses' Association file to their respective polling places to vote whether to ratify their new contract, they are faced with the reality that safe patient care in general and "safe" staffing levels in particular are going to be a complex and protracted endeavor.

However, before they even attempt to engage their respective hospital administrations in a discussion about patient safety, nurses need to arrive at their own, specific definition of "patient safety."
Of course, everyone wants patients to be "safe." Do all parties mean the same things by the word "safe"? Corporations, most recently Toyota and British Petroleum, are notorious for a more elastic definition of "safe." Classically, corporations will comply with the letter of the law, but no more. Any additional safety initiatives are closely monitored, and are considered a success if they save at least as much money (in the form of litigation fees, fines, settlements, and so on) as they cost. If they don't, no matter how much improved safety is realized from the program, it's "financially unsupportable."
Nurses have a more stringent definition...somewhere. It's difficult to define patient safety, and tease it out from such phenomena as optimal care or a busy patient assignment. Does it necessarily follow that not getting a meal break means patient safety was at risk? Some say yes, some say no, some simply aren't sure.
Moreover, is "safe patient care" enough? I would contend that safe patient care is a component, but not the totality of either effective patient care or optimal patient care, both of which beg their own definitions. When the best I can say about my shift is, "I gave really safe care," I'm trying to console myself, not congratulate myself.
In my evidence-based practice research around patient falls prevention, it occurred to me the interventions to prevent falls broke down into three categories:

1. Decreasing the number and intensity of risk factors.
2. Supporting, improving, and increasing the patient's adaptive behaviors to prevent falls.
3. Interrupting behaviors that increase patient falls risk.

It occurs to me that safe patient care requires similar capacities from the caregiver. Specifically:

1. Identification of risk factors, events, or processes that increase the exposure of the patient to harm.
2. Intervention to decrease or eliminate these risk factors, events, or processes, thereby decreasing the risk of harm to the patient.
3. "Rescuing" the patient from emergent harmful situations.
4. Adequate resources (personnel, equipment, training) to carry out these safety activities.

I can't even guess if this is a workable definition, or even the foundation for someone else to develop one. I do know, however, that if we can't clearly define what we consider "safe patient care," we can't measure it and we can't effectively advocate for it. It requires profound limberness of logic to insist that because you can pay for whatever damage you've caused and no one was hurt (much), you're a safe driver. Unless we have a definition with more veracity, this may well end up stuck with this one.

Safe patient care is not excellent patient care, but excellent patient care is safe patient care. Until we have a standard to which we can compare the caregiving circumstances we face, we will be unable to truly know what is required to provide safe and excellent patient care. And odds are, we'll end up providing neither.

The Slippery Slope to a Holy War

I am seeing a few scatter signs that the quest for safe staffing is becoming a "holy war." This concerns me, and it concerns me a lot.

The conditions needed for a holy war is that each side believes something very strongly, and just as strongly believes the position held by the other party is antithetical to their own position. Accepting, at least for now, each side's position is sincere as presented:

• Nurses believe safe patient care requires mandated staffing ratios, and Management has more than adequate resources to cover the additional cost.
• Management believes safe patient care requires solvent and financially stable institutions, with a high degree of flexibility to exactly meet demands for nursing services, and mandated ratios are financially unsupportable.

As each side lacks the data to prove their position, they are operating from belief, from faith. Faith is impervious to debate, it is cannot be proved or disproved, and each side holds its "articles of faith" as sacred while holding their opponent's view as profane.
As I follow postings on the MNA Facebook page, I see other complementary and disturbing trends, also consistent with preparations for a "holy war":

• Those outside the group (in this case, MNA) who do not share the articles of faith (the hospitals) are infidels; they must be vanquished.
• Those inside the group who do not share the articles of faith are heretics; they must be found and cast out.

Herein lies my problem. As Robert Langdon put it in Angels and Demons, "Faith is a gift I have yet to receive." I occasionally envy the serene confidence that marks people of faith: a Christian with four aces is truly a wonder to behold. That envy is not compelling enough for me to desire this "gift." I claim as my gift the ability to see the grays and notice the nuances. The universe is complex, simple answers do not satisfy, and the search for the complex and nuanced answers is endlessly fascinating. I will not surrender my gift, no matter how inconvenient my vision is for myself or others.

This is unease is compounded by history. Crusades seldom work out well for the crusader: the infidels are well armed and have the home-field advantage. I fear that if MNA decides to embark on this crusade, we won't fare any better and likely will suffer greatly for our efforts.

The importance of patient safety is inarguable; it must be enhanced and assured. Nurses' professional integrity is an obligation of every professional nurse, and a demonstrated component of safe patient care. Required staffing ratios are one of many paths; true believers' assertions to the contrary. There are many others to be investigated and tested, with care and deliberation, lest our "cure" (like so many in our history) creates a new and more dangerous disease.

I profess no faith, only provisional trust. More generous provisions must be earned. Mandated staffing ratios have not earned that even my most provisional trust.

And I will not march into any conflict on the basis of faith.

Into the Whitewater

As a nurses’ strike appears all but inevitable, I find myself in both unfamiliar, but also strangely familiar territory.

This is the first time I’ve worked at a unionized hospital, and the first time I’ll be participating in an open-ended strike. All this is new and unfamiliar. Yet what I feel as I approach the strike date feels oddly familiar.

Once again, I’m heading into the whitewater.

I’m hardly an expert whitewater rafter. I’ve been on a few two- to six-hour trips, on rivers that were wild and dangerous enough to be fun and keep me on my toes, but not so much as to be truly frightening. Unless something extraordinary happened, I had reasonable confidence I’d come out the other side soggy, but unscathed.
I don’t expect the strike to be fun. It will be turbulent, and I’ll need to pay attention, but I expect to come out the other side more-or-less unscathed. Still, some of the lessons from riding the real whitewater seems relevant to what we will likely be facing in the days and weeks that come:

• Pay attention: There will be a lot going on, so pay attention. There will be things you need to do and instructions you’ll need to follow. I know I have a bad habit of retreating into my own head (hey, it’s an interesting place), but it’s unwise, and at least occasionally dangerous in situations like this. Stay alert, and be “present.”
• Listen to your guide: Some people have been down this “river” before; they know how to read it and know what the hazards are. Listening to and following their instructions is the most reliable way to both get the boat down the river safely and keep from going for an unscheduled swim.
• Row: You aren’t a tourist here, you’re a participant. Do your part and participate!
• Don’t pass up any lines thrown to you: Should you end up taking that unscheduled swim, people will yell to you, “Swimmer (that’s your name now)! Throwing line!” A rope will land coming over your shoulder. Get a tight hold, hold it tight to your chest, and let yourself be pulled to the boat or shore. “No, thanks…I’ll be alright” is both unnecessary and inappropriate. Whitewater swimming can become whitewater drowning all too easily.

In the whitewater ahead, there will be a lot going on, so pay attention and stay informed. Many of our union leadership has been down this river before, so listen up and follow instructions. Walk the line and speak up when asked; we’re all spokespeople for our cause. Don’t pass up any assistance that comes your way. The links on the MNA web site and Facebook page list ropes that have already been thrown to you. It’s up to you to grab them.
Few people will find the river ahead to be an enjoyable adventure. That’s okay. Being paralyzed with fear isn’t an option, either. Be present and participate, and you may find the ride more fun than you expected. At the very least, once we reach the calm on the other side of the rapids, you will have the satisfaction of knowing you made it through.

Q & A

The following is a message I received via Facebook. Identifying information has been removed.

I work at one of the Twin Cities Hospitals. Yes, I voted to strike. If I posted the question I am going to ask you on the MNA page I would get my head bitten off.....Out of 12,000 eligible nurse votes, less than 9,000 voted, something like 8700.Out of those 8700 (less than 75% of the nurses) 87% voted to strike. That is only 63% of Twin Cities nurses voting to strike. How is that overwhelming?!

My Answer:

If this was a survey, you would say you had a voluntary sample of 8700 out of a population of 12000 (roughly 73%). Although the Office of Management and Budget requires a sample size of >80% for surveys to be used for government policy-making, >70% response is considered adequate for most academic purposes, and reasonably reflective of the studied population. 63% of the population is still significant, beyond any margin of error, and would be a filibuster-proof majority in the US Senate. Using the same math, you can also say that 9.5% of the MNA nurses voted against the strike. In that 3300 members didn't vote, the actual support of the strike could be anywhere from 63% to 90.5%. We'll never know.
However, this was not a survey; it was a vote. That is, it's a way for us to contribute to a decision-making process, to directly instruct our bargaining teams in what we want them to do. Thus, only those who participate matter. A 73% turn-out for any election is well above the norm, although more would have been better.
I, also, despair that someone with a sincere question or declines to see things in black and white is ridiiculed, viewed with suspicion, or both. It may be the way things are in situations like this, but that doesn't mean I have to like it or support it.

Perhaps it's time to set aside the torches and pitchforks, and at least for now, call off the witch hunt. Such scourges against those lacking "ideological purity" always do more harm than good.

Living My License

Early this week, nurses voted to allow their negotiating teams to call an open-ended strike if they deem necessary, and I voted with them. You may well wonder why I consider this necessary. In short, this vote was the natural consequence of living my license.
Because I am licensed by the State of Minnesota and not by Abbott Northwester Hospital or Allina Health Systems, I have an independent responsibility to my patients. Because I am a licensed professional, I also have a responsibility to my profession. And just because I’m a grown-up, I have responsibilities to myself. Living my license involves all three spheres of responsibility, and it’s at the heart of these contentious negotiations.
That nurses have an independent responsibility to our patients is most clearly evident in the operating room. In addition to the surgeon and the anesthetist, there are two additional critical roles, the “scrub” and the “circulator.” The scrub may be, but seldom is, a nurse; he or she passes instruments as called for by the surgeon, and keeps track of needles, blades, sponges, and other items on the tray. The circulator is always a nurse, and is the interface between the sterile surgical field and the non-sterile world. The circulator also watches everything: he or she can stop the surgery because the sponge count is off or sterile technique is broken or any number of other reason. This might annoy the surgeon, but that doesn’t matter. The circulator is there to protect the patient, not the surgeon’s ego.
The major sticking point in our contract negotiations is around staffing levels. How many nurses does it take to care for this many patients, and who gets to decide? While facilities in the Twin Cities staff better than many places in the country (I know, I’ve been there), it still may not be enough. Patients are sicker, and the components of safe patient care are continually becoming more numerous and more complex. When I, as a charge nurse, call for more nurses than our staffing scheme allows, it is for concerns of safety, not so we can catch up on our online shopping and not to torpedo the hospital’s bottom line.
This also reflects my responsibility to my profession. Administrators do not, and cannot, know what it takes to provide care to patients on a day-to-day, shift-to-shift, hour to hour basis. They aren’t there. I am. We are. It has been so thoroughly demonstrated that the closer the decision making gets to the point of service, the better the decisions, it’s practically a law of nature. Part of our professional duty is to determine how our services will be provided. Determining the number of nurses needed to take care of patients is an important part of that professional control.
We are individually and collectively responsible for ourselves. Assuring the solvency of our pension fund and the stability of our health insurance is in our personal best interests. We understand that neither of these are inexpensive propositions, and will negotiate on them because it’s also in our best interests to have solvent and stable workplaces. However, it’s our responsibility to look out for ourselves, rather than hoping someone else will.
Living our license can be tough work. Holding a picket sign in the rain washes away romantic illusions, leaving the unyielding realities of our responsibilities. Standing up to a temperamental physician can be nerve-wracking, but critical. We are independently responsible to our patients. We are responsible to our profession. We are responsible to ourselves. It is out of these responsibilities that we make our voices heard and presence known, early this week and in these days that follow. It is ironic how much our employers depend on us to live our licenses and take these responsibilities seriously, even with the resulting expense and inconvenience they find so encumbering. We take these responsibilities seriously because we understand who and what we are. We are professional nurses. Allina isn’t health care; Abbott Northwestern Hospital isn’t health care. We are health care. I am health care.

Unfrozen

One change management theory posits that change is accomplished by "unfreezing" current ways of doing things, rearranging to a different configuration, then "refreezing" the changes into place.
As the Minnesota Nurses' Association and a number of Twin Cities hospital systems square off during contract negotiations and another likely strike, things are seriously unfrozen. Normally, the change process is carried out carefully and intentionally. Well, not this one. Change is coming, and no one really seems to know either what we're transitioning from or transitioning to. Neither side is articulating a vision for high-quality and sustainable health care.
MNA demands from employers concessions that run afoul of a particular from Matt Miller's The Tyranny of Dead Ideas. Specifically, "My company should take care of me." Much of the health care and all the pensions provided for MNA nurses are funded by the employer. The costs of these benefits, according to the employer, are becoming unsustainable. Perhaps they are. Even if they aren't, perhaps it's time to remove these benefits from the employer's pervue: they will no longer have to fuss with it and we will no longer feel blackmailed into staying someplace we'd rather not be.
The employer, on the other hand, fails to understand something that must be grasped with utter clarity: hospital nurses are not just the "face of health care" within their facility, they are health care. Whatever the proposal, from changes in the supply chain to staffing patterns, the first question must be, "What impact will this have on the nurses' effectiveness?" If other questions are being asked instead, too often it's because the effect on nursing care is already understood to be negative. Ditto if anyone but nurses are called upon to answer the question.
Nurses need a financially viable venue in which to practice. Hospitals need a dedicated, professional, and effective nursing staff. Both need to provide for the other in ways that are sustainable and make it more likely to get what they need from the other party. That neither side really seems to know what that looks like leaves everyone feeling like they're living a Despair.com poster.
Right now, everything is in flux, in chaos, unfrozen. Anything is possible. Of course, "anything" includes utter disaster. It also includes the possibility of extraordinary adventure and even extraordinary success, a success that meets everyone's needs and exceeds everyone's expectations.
Does either side realize this, and is either side willing to reach for this, work for this, and convince the other side that it's possible?
I hope so.

The Rest of the Equation

The statement "nurses eat their young" has been so often repeated it has become axiomatic. "Lateral" or "horizontal" violence is a very real issue in professional nursing (among other occupations), it has been heavily researched, and various interventions and corrective actions have been initiated with varying levels of success.
There are "zero tolerance policies;" there are defense strategies for new nurses to use to protect themselves. But are we missing half the equation?
Lateral (or horizontal) violence describes how members of an oppressed culture, unable to strike back at their oppressors, instead take out their anger and frustration on the more vulnerable members of their own group. In the nursing profession, this is usually new hires and those newly graduated from nursing school. The consequences of lateral violence are dire: new nurses are often driven out of a particular work environment and perhaps out of the profession altogether. As the current nursing shortage is likely to only worsen, this has grave implications for the accessibility and quality of health care.
As grave as the problem of lateral violence is, all the interventions are directed at the behaviors: how to defend against the behaviors, how to identify and punish perpetrators. Certainly, lateral violence is reprehensible, unacceptable, and professionally self-sabotaging. But what about the other side of the equation?
As lateral violence is endemic to oppressed cultures, shouldn't the issue of oppression be addressed? How might lateral violence be affected if there were other, more benevolent, more productive opportunities to wield power?
Certainly, there are many aspects of professional nursing practice that are non-negotiable: patients require care, competencies must be maintained, and standards must be met. However, it does not necessarily follow that in order to do everything that must be done, every step must be prescribed and every process delineated, with every deviation or innovation at least suspect if not outright punishable.
Nurses, by training and by licence, are independently accountable to the patient and are expected to exercise professional judgement and critical thinking. We are taught to negotiate with patients to develop a plan of care that best meets their needs. However, we are seldom extended the same courtesy.
Work schedules and shift availability is on a take-it-or-work-elsewhere basis, patients are assigned, seldom selected by the nurse. These sorts of problems are hardly unique to nursing, and professions that experience similar working conditions also have similar problems with lateral violence.
For nursing to be a profession, we must be responsible to our patients, our profession, society, and ourselves. As professionals, we have the right to negotiate how we meet each of those responsibilities. Every professional knows that these responsibilities often conflict, and the give-and-take among them is a part of professional reality.
Participating in this negotiation, both collectively as a profession and individually as a professional is the other side of the equation that must be addressed for effective control and eventual eradication of lateral violence. All the interventions addressing behaviors associated with lateral violence must continue to be addressed, but it's past time that addressed the rest of the equation.

In Our Best Interests

The big showdown looms, but as what passes for debate concerning health care reform rages in the halls of Congress, twitters among the puditocracy, and clashes in town-hall shouting matches, I fear there is nothing everyone can support. The key may lie in identifying what no one can argue against.
“It is in this country’s best interests that each of its citizens be at his or her optimal level of health.”
Add any politically relevant adjective you like between “best” and “interests”: can the premise be refuted?
It is in the country’s best business interests. Healthy workers are productive workers. Healthy workers decrease the burden of health care costs on employers, allowing greater resources to be applied in improving the company’s competitiveness. This is particularly important when the competition is overseas, drawing from a healthier labor pool than American companies.
It is in the country’s national security interests. A healthy citizenry is better able to take up arms in defense of the nation should the need arise. More importantly, healthy citizens are more resilient in the face of disaster, be it of natural origin, rooted in human shortcomings, or a bioweapon attack.
It is in the country’s economic best interests. Beyond the benefits to business, citizens in optimal health are best able to both labor and enjoy the fruits thereof. That enjoyment will certainly involve healthy, prudent, and sustainable levels of consumption that will keep the economic engines turning and allow for broader levels of comfort and prosperity.
The premise “It is in this country’s best interests that each of its citizens be at his or her optimal level of health” is simple and straightforward, but with far-flung implications. These implications will surely need to be thoughtfully discussed and actions will need to be carefully chosen. This is the debate that should be occurring.
If the U.S. Chamber of Commerce concluded “Healthy citizens are good business,” what recommendations would it make to its members? How would Wall Street react to those recommendations?
If the health of each American citizen was identified as a Homeland Security issue, how secure would you feel we are? What would be government’s responsibility? What would be our patriotic duty?
If the optimal health of every American became the national economic priority, how would the role of health insurance change? How would the activities of all business change when they are expected to “do good” for the health of their employees and customers, not merely “not provably do harm”?
It even would be productive to debate the premise itself, especially compared to the rancor currently flooding the airwaves and hearing rooms. The argument would be terribly lopsided, but it would flush out those more concerned with their self-interests, as opposed to the country’s best interests. It might finally put to rest arguments over what is patriotism, and what is not.
Any takers?