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Department: Evidence-Based Nursing

Applying Lean Six Sigma to evidence-based practice projects

McCoy, Cole MPS, BA, BS; Douglas, Claudia DNP, RN, APN

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Nursing Management (Springhouse): May 2022 - Volume 53 - Issue 5 - p 35-39
doi: 10.1097/01.NUMA.0000829276.81512.69
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Evidence-based practice (EBP) is a systematic approach for applying the best available evidence from research into clinical practice. With more than 47 defined EBP models in the literature, nurses are well versed on these models and their structure; however, implementation of new evidence from the point of discovery to standardization into clinical practice can take 15-17 years.1,2,3 As advancement and discoveries in medical science accelerate and reshape clinical knowledge, translating evidence into practice continues to be a pivotal gap.

Initially, our organization focused on educating staff to search and appraise the best evidence and develop the PICOT (problem, intervention, comparison, outcomes, time) question; consequently, the process of incorporating new EBP findings into practice proved to be a challenge. A retrospective review of our previous approach revealed barriers to integration, execution, and sustainability. Faced with this realization, we applied Lean Six Sigma (LSS), a process improvement methodology, to overcome the implementation barriers within our organization. Because LSS was familiar to our organizational culture, we successfully leveraged this framework within the EBP implementation process.

Barriers to implementation

Nursing, now more than 3.8 million strong, is the largest segment of healthcare professionals in the US. Because nurses are inextricably embedded and uniquely positioned in the healthcare infrastructure, their potential as catalysts for the meaningful application of the growing body of scientific evidence in both medicine and nursing presupposes their potential to bridge the gap in knowledge transfer from discovery to the bedside. As new scientific evidence in healthcare continues to advance and proliferate, the question of how best to transfer this knowledge into clinical practice and policy highlighted the need for a paradigm shift and redesign in our EBP implementation process. The literature is replete with systematic quantifiable proof of EBP as the gold standard in patient care, but incremental gains demand investigating different implementation strategies to promote timely translation of evidence into practice. Although there's strong clinical interest in timely integration of new knowledge into practice, these high expectations aren't always achieved; therefore, understanding how to facilitate and sustain EBP implementation is critical.5 Facilitators of our nurse residency program explored implementation science to complement the development of nurse residents' EBP projects and their operationalization into clinical practice.

In the fall of 2019, nurse residents were required to initiate a new clinical practice on their units. It soon became evident that the successful development and implementation of EBP projects would entail more than formulating the PICOT question. Furthermore, the notion that simply presenting the evidence from literature would be sufficient to galvanize change in current outdated practices didn't take into consideration intrinsic barriers (such as statistical proficiency and knowledge of implementation science) and extrinsic barriers (such as stakeholder engagement, organizational prioritization, and resource constraints). Although EBP's value is firmly established in nursing, effective engagement and collaboration among diverse stakeholders isn't always factored into the implementation plan, which results in subsequent barriers when stakeholders aren't engaged and there's insufficient leadership support.6,7 Translational science is strengthened by the application of LSS because it encapsulates a broader structural context, including human factors, existing structures, available resources, and current processes. Therefore, to facilitate and support our nurse residents with the implementation of their EBP projects, we incorporated LSS into the process.

Incorporating Lean Six Sigma

The rigorous data-driven LSS methodology combines Lean culture with Six Sigma methodologies in a complementary mechanism. Lean achieves its goals by assessing the workplace infrastructure, identifying waste reduction techniques, and implementing visual controls for sustainability. Six Sigma uses statistical analysis, qualitative and quantitative techniques, and scientific rigor to minimize variation in implementation.

Originally developed for the business setting, LSS has seen recent application in the healthcare industry, specifically in addressing safety concerns, improving workflow, and resolving identified problems.8 By applying a systematic approach for operationalizing sustainable processes, LSS incorporates continuous improvement and ensures alignment with the intended outcomes, thereby fostering a culture of change rather than a singular application.9,10 Using this method, newly applied evidence is refined through constant iterative cycles, where each deployed change integrates into a consistent and sustainable process.

The true power of LSS lies not only in its broad overview of the problem within the organizational context but also in its forethought of defining the problem, anticipating barriers, and assessing the feasibility of the proposed solution before proceeding to implementation of practice changes. LSS leverages the perspectives of interdisciplinary teams to assess the problem, formulate the most appropriate clinical question, and develop the most suitable processes for implementing EBP within the constraints of existing resources and capabilities.

Institute aids EBP process

Established in 2014, our Institute for Evidence-Based Practice & Nursing Research provides support to nurses conducting research studies, EBP projects, and implementation science projects at our hospital. Beginning in 2019, our institute, in collaboration with the Department of Clinical Education, was charged with assisting the newly graduated nurses as they worked to complete their EBP projects during the 12-month duration of their residency. Nurse scientists within the institute held sessions with the nurse residents to review the residents' progress and to support them through the process of developing and implementing EBP projects on their assigned units.

Because our first case study for EBP implementation was the October 2019 cohort, we initially reiterated the process of searching, reviewing, and appraising the literature, identifying the EBP problem, and establishing the PICOT. Although the residents had a firm grasp of the EBP framework, it quickly became apparent that the true gap was in implementing the EBP projects on their units. Residents easily developed the problem description, the EBP question, and the PICOT, but they failed to incorporate available resources, procedures, and stakeholders necessary to translate the identified new knowledge into standard clinical practice within the high-velocity healthcare environment. In addition, the COVID-19 pandemic caused time constraints and redeployment of human capital resources, further highlighting the need for a systematic coordination of project implementation efforts. When reviewing the EBP project plans, we identified the need for a precise strategic approach to maximize the current capabilities and capacity of organizational resources available for implementing new clinical knowledge. This included an accurate and realistic understanding of the current parameters of resources, people, and culture, employing the expertise of cross-functional collaborators, and using these aspects to truly understand the problem and implications of integrating EBP into the clinical environment. Our institute leveraged the LSS methodology, specific to the DMAIC (Define, Measure, Assess, Improve, Control) model, to provide a consistent, stepwise approach to reduce barriers to EBP implementation. Consequently, we incorporated LSS concepts within the EBP implementation process, which resulted in the creation of the Translational Science Model for EBP Implementation (see Table 1). This model demonstrated a reduction in time, from identification of the problem to implementation, and provided a sustainable model through which nurse residents could optimize organizational resources and engage stakeholders to successfully integrate new best practices at the bedside.

Table 1::
Translational Science Model for EBP Implementation

When we used the Translational Science Model for EBP Implementation with the 2019 and 2020 cohorts, we noticed an immediate difference in how the nurse residents implemented their EBP projects (see Table 2). First, they had great success engaging stakeholders from the start to identify the root problem and the best solution to address that problem. Second, the residents creatively used existing structures and resources to integrate new knowledge into their clinical practice with leadership support. By leveraging existing human resources and current processes, nurse residents collaborated with day, evening, and night shifts, used interdepartmental partnerships, presented their evidence-based implementation plans to get the input and support of the appropriate councils, and employed the shared governance structure to garner support and disseminate the achieved EBP project outcomes. An example to illustrate the Translational Science Model for EBP Implementation was the 2020 cohort's EBP project, “Nursing interventions in managing premature neonates experiencing gastric content reflux.” Residents determined there was no standard guideline on managing neonates with symptoms of gastric reflux in the neonatal intensive care unit. Using the Translational Science Model for EBP Implementation, the nurse residents collaborated with interdisciplinary partners to create an evidence-based solution to the problem; engaged leadership, appropriate councils, and shared governance to approve the project plan; and leveraged the capabilities of existing human and organizational resources to successfully implement the new EBP plan (see Table 3).

Table 2: - Number of implemented EBP projects per nurse resident cohort yeara
Nurse resident cohort year # of implemented EBP projects
2019 27 projects
2020 57 projects
aDerived from Institute for Evidence-Based Practice & Nursing Research records

Table 3::
Translational Science Model for EBP Implementation

The big picture

Transformation of a single process can have significant organizational repercussions as any diverted resources or adapted processes may cause a ripple effect throughout the organization. By using LSS to implement EBP into clinical practice, maximum performance is obtained from the current capabilities and capacity of organizational resources while identifying and addressing anticipated barriers to implementation. By identifying the maximum capabilities of human resources and processes, a realistic prediction of potential performance and outcomes can be achieved to assess the feasibility of implementing a practice change and avoid barriers to implementation when taking into consideration the current parameters of resources, people, and culture. Thus, the Translational Science Model for EBP Implementation demonstrates the ability for timely and consistent integration of new knowledge into nursing practice by identifying the broader scope of the problem and the appropriate metrics for evaluating the intended changes on a sustainable basis. As evidenced by our findings, combining LSS with EBP has substantial implications for implementing new knowledge and best evidence into practice.


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