Distinguishing Between Quality Improvement,
Evidence-Based Practice, and Nursing Research
Maria R. Shirey, PhD, MBA, RN, NEA-BC, ANEF, FACHE, FAAN
Professor, Community Health, Outcomes & Systems
Assistant Dean, Clinical Affairs & Partnerships
University of Alabama at Birmingham School of Nursing
North Dakota Center for Nursing Conference
October 23, 2014 • Bismarck, North Dakota
Introduction
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So … How Did You Get Here?
“Showcasing Differences
Between Quality Improvement,
Evidence-Based Practice,
and Research”
Winner of the inaugural JCEN
Innovation Award for 2011
Shirey et al., (2011)
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Impact
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Presentation Objectives
• Differentiate among quality improvement (QI),
evidence-based practice (EBP), and nursing research
Realistic Expectation:
Gain general understanding of concepts and their application
Reflect and brainstorm to use information more broadly
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Road Map
• Overview of the Shirey et al., (2011) article
• Application of article by others
• Reflective dialogue with next steps
• Key takeaways with Q&A
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Overview of the Article
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Why Is There Need to Know?
• Recent meta-analysis identified all concepts as essential for
Magnetic, healthy nursing workplace (Kramer, Schmalenberg &
Maguire, 2010)
Research
Quality & Safety
of Patient Care
QI
EBP
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Important Definitions
Quality Improvement
Data driven systematic approach by which individuals
work together to improve specific internal systems,
processes, costs, productivity, and quality outcomes
with an organization
Note: Terms QI and Performance Improvement (PI)
used interchangeably
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Important Definitions
Evidence-Based Practice
Problem-solving approach that integrates a systematic
search for and critical appraisal of the best available
evidence (may or may not be research based) to
answer a burning clinical, education, or administrative
question
Clinician expertise and patients’ unique
circumstances and preferences
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Important Definitions
Research
Scientific process that generates new knowledge and
validates/refines existing knowledge that directly and
indirectly influences nursing practice or health systems
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Background and Overview of the Article
• Started as discussion board assignment in DNP course
• Intent of assignment was to compare and contrast all 3
concepts of QI, EBP, Research across multiple dimensions
• No article available with extensive side-by-side comparative
data, so … we created one!!!
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Building The Comparative Table
Synthesis of the Literature
Main Categories
QI
EBP
Background and
descriptors
Uses and
Applications
Scholarship
Integration
Shirey et al. (2011)
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Research
Highlights of Comparative Table
Main Categories
with Dimensions
QI
EBP
Research
Deming; production
quality monitoring
Cochrane; scientific
evidence used to
guide practice
Nightingale; scientific
method of discovery
in nursing
• Commonalities
and distinctions
Systematic problem
solving approach that
is data driven
Systematic problem
solving approach that
is evidence driven
Systematic problem
solving approach that
is inquiry driven
• Key features
Incorporates
knowledge
Translates
knowledge
Generates
knowledge
• Rigor
Least rigorous
Somewhat rigorous
Most rigorous
Background and
descriptors
• Historical
evolution
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Highlights of Comparative Table
Main Categories
with Dimensions
QI
EBP
Improve internal
processes to
enhance outcomes
Evaluate evidence and Develop new
integrate into practice knowledge that is
to enhance outcomes generalizable
• Use of
protocols
Yes; changing
Yes; systematic
Yes; strict
• Data
collection
Rapid cycle
Intermediate not
rapid cycle
Not rapid cycle
• IRB approval
Not usually; may be
needed for pubs
Not usually; may be
needed for pubs
Always; required for
publication and to
initiate study
Uses and
Applications
• Purpose
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Research
Highlights of Comparative Table
Main Categories
with Dimensions
QI
EBP
Research
Uses and
Applications
• Funding
Usually internal
Usually internal
May be internal or
external
• Oversight
Institutional
Institutional
Beyond institution
• Limitations
Weak methodology;
no causality
Outcome only as
good as “best”
evidence
Depending on
analysis can establish
causality
• Methodology
Various QI
approaches
i.e. PDCA
Various EBP models
i.e. ARCC model
(Melnyk & FineoutOverholt)
Various
methodologies
i.e. qualitative,
quantitative or
mixed methods
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Highlights of Comparative Table
Main Categories
with Dimensions
Uses and
Applications
• Examples
QI
EBP
Research
PDCA project to
improve door to
balloon times in
acute myocardial
infarction patients
Implementation of
protocol for early
post operative
patient ambulation
following release of
landmark systematic
review
Qualitative research
to describe nurse
manager work
complexity
PDCA project to
reduce 30-day
hospital readmission
rates in heart failure
patients
Translation of best
evidence into
practice to enhance
outcomes
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Highlights of Comparative Table
Main Categories
with Dimensions
QI
EBP
Research
No
Varies
Usually yes
• Generalizability
No
Yes, with caveat
Yes, with caveat
• Expectations for
dissemination
Within facility
Within facility and
beyond
Broad dissemination
to scientific
community
• Potential for
dissemination
May be publishable
May be publishable
Usually publishable
Scholarship
Integration
• Theoretical
underpinnings
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Highlights of Comparative Table
Main Categories
with Dimensions
Scholarship
Integration
• Examples of
venues for
publication
• Examples of
venues for
presentations
QI
EBP
Research
Journal for
Healthcare Quality
Worldviews on
Evidence-Based
Practice
Nursing Research
NAHQ conferences
EBP conferences
Nursing research
society conferences
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Understanding Check
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Understanding Check
Question #1
If the intent of a project is to establish a cause-andeffect relationship, the best approach to use would be
a/an:
A. Evidence-Based Practice Project.
B. Quality Improvement Project.
C. Research Project.
D. Institutional Project.
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Understanding Check
Question #2
Given the following choices to develop an EBP project,
the best methodology to use would be:
A. Six Sigma.
B. Plan Do Check Act.
C. The Academic Model.
D. The Iowa Model.
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Understanding Check
Question #3
Given the choice between various approaches, a team
developing a clinical work flow process using limited
resources and time would likely select:
A. Nursing Research.
B. Evidence-Based Practice.
C. Quality Improvement.
D. Clinical Inquiry.
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Understanding Check
Question #4
The definitive dimension the distinguishes between
quality improvement, evidence based practice, and
research is:
A. Historical Evolution.
B. Definition.
C. Rigor.
D. Purpose.
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Application of the Article
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The Application
Tool for Academia
• Guide for teaching QI, EBP, Research in academic
programs
• Incorporated in teaching QSEN principles
(American Association of Colleges of Nursing QSEN Institute Faculty Resources)
• Referenced in numerous professional websites
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The Application
Tool for Clinical Nursing Excellence
• Support Nursing Standards of Practice (ANA, 2010)
At fundamental level, the registered nurse participates
in QI activities and integrates EBP and research into practice
• Accelerate Hospital Magnet Journey
→ Guide to decipher which approach to use
→ Identify need for IRB approval
→ Create Magnet evidence
• Form foundation for additional user-friendly staff
development resources for clinical practice (Ryan & Rosario, 2012)
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The Application
Tool for Clinical Nursing Excellence
Performance Improvement/Research Differentiation Form
(Ryan & Rosario , 2012)
• Identify title of project
• Answer series of questions
• Determine pattern of responses
• Identify emerging dominant study category
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Ryan & Rosario
(2012)
Performance
Improvement
Research
Which phrase
best describes
purpose of the
project?
To improve internal
organizational
processes, practices,
costs or productivity
To generate new
knowledge that can be
generalized
What are you
trying to
accomplish with
this project?
To measure an existing
practice that is an
approved procedure or
that has been shown
effective in the
literature
*** To test or refine an
innovative practice or
instrument
Will participants
be placed at any
risk during
project?
The project does not
impose risks beyond
usual care
*** The project may
impose some risk to
participants
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Uncertain
Ryan & Rosario
(2012)
Performance
Improvement
Research
What does the
intervention in
this project
involve?
The project involves
applying practice
standards or evaluating
existing practice without
group comparisons
The project involves
comparisons of one or
more interventions that
are given to some
patients and not others
How are the
processes or
outcomes
measured?
A data collection tool that
has not been tested for
reliability and validity is
used
An instrument that is a
valid and reliable
measure of the concept
to be tested will be used
What do you
plan to do with
the findings?
Communicate findings
within the hospital or
department setting.
Findings may be
published and/or
presented.
Publish and/or present
findings for others within
the discipline
How will your
findings change
practice?
May change practice in
this setting immediately
May change practice
slowly, often after
multiple studies validate
the results
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Uncertain
The Application
Tool for Dissemination
Different Formats for Publication of QI, EBP, Research
Oermann, Turner & Carman (2014)
QI
SQUIRE
Research
EBP
IMRAD
PRISMA
Guidelines
for
Reporting
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Guideline
Definition and Website Resource
QI
SQUIRE
Standards for Quality Improvement Reporting
Excellence
http://squire-statement.org/
Title, Abstract,
Introduction,
Methods, Results,
Discussion, Other
Information
EBP
PRISMA
Preferred Reporting Items for Systematic Reviews
and Meta-Analyses
http://www.prisma-statement.org/
Title, Abstract,
Introduction,
Methods, Results,
Discussion, Funding
Research
IMRAD
Introduction, Methods, Results, and Discussion
Title, Abstract,
http://writingwisc.edu/Handbook/ScienceReport. Introduction,
html
Methods, Results,
Discussion,
Limitations,
Conclusions,
Implications,
Funding
The Application
Tool for Dissemination
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Categories
Application Check
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Application Check
Scenario #1: QI
• The hospital examines its monthly run charts on key
quality indicators
• In reviewing these data, the hospital determines the
incidence of falls in hospitalized elderly patients is
trending upward
• To act on this information, what should happen next?
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Application Check
Scenario #1: QI
• Formulate QI question:
Why is the unit level fall rate so high?
• Apply QI methodology
P Identify and analyze problem
D Develop and test solutions
C Check effect of pilot solution
A Implement solution fully
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Application Check
Scenario # 2: EBP
• There is a desire to initiate a practice change that
would prevent falls in hospitalized elders
• To initiate a practice change, what should happen
first?
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Application Check
Scenario # 2: EBP
• Formulate clinical question using PICOT format:
P
Population
I
Intervention
C
Comparison
O
Outcome
T
Timeframe
In hospitalized elders (P), how does a bed alarm (I) compared
to use of sitters (C) affect fall rates (O) during a 3 month time
period (T)?
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Application Check
Scenario # 2: EBP
• Specify key search terms to retrieve evidence that best
answers PICOT question and meets inclusion criteria
• Generate evidence table and determine level of evidence
• Critically appraise the evidence (look at flaws and worth)
• Make practice recommendations based on best evidence
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Application Check
Level 1- Systematic review & meta-analysis of RCT
Level 2- One or more randomized controlled trials
Level 3- Controlled trial (no randomization)
Level 4- Case control or cohort study
Level 5- Systematic review of descriptive & qualitative studies
Level 6- Single descriptive or qualitative study
Level 7- Expert opinion
Melnyk & Fineout-Overholt (2011)
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Application Check
Scenario # 3: Research
• You have searched the literature to obtain information about
the incidence of falls in hospitalized elders
• You find the literature is not current and it does not
incorporate cultural aspects pertinent to your unique elderly
patient population
• How do you go about developing a permanent solution for
elderly patient falls in your patient population?
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Application Check
Scenario # 3: Research
• Identify problem statement
• Formulate research question:
What factors contribute to falls in non-English
speaking hospitalized elderly patients?
• Use research question to guide methodology (design,
sampling, data collection, data analysis methods)
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Reflection with Next Steps
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Stretch and Energize to Focus
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Reflective Question
Now that you have heard this presentation,
what ideas do you have for HOW you would
immediately begin using the information in your
practice and work setting?
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Think, Pair & Share
• Turn to person next to you
• Discuss the following for 5-minutes:
How would you begin to immediately use the information
from this presentation in your practice and/or work setting?
What partnerships or networks might you leverage? Why?
• Take 5-minutes to share your ideas with the broader
audience
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Synthesis Check
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Key Takeaway Points
• Correctly differentiating among QI, EBP, and research =
→ Essential for patient care quality/safety
→ Needed to advance nursing practice and science
• Understanding concept differences enhances
applicability, integration, collaboration opportunities,
and ultimately our IMPACT
• Proficiency comes from learning and doing
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Closing
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Questions & Answers
Maria R. Shirey, PhD, MBA, RN, NEA-BC, ANEF, FACHE, FAAN
Professor, Community Health, Outcomes & Systems
Assistant Dean, Clinical Affairs & Partnerships
University of Alabama at Birmingham School of Nursing
mrshirey@uab.edu
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References
American Nurses Association. (2010). Nursing scope and standards of
practice. Washington, DC: ANA.
Kramer, M., Schmalenberg, C.& & Maguire, P. (2010). Nine structures and
leadership practices essential for a magnetic (healthy) work environment.
Nursing Administration Quarterly, 34(1), 4-17.
Melnyk, B. & Fineout-Overholt, E. (2011). Evidence-based practice in nursing
and healthcare: A guide to best practice. Philadelphia: Lippincott, Williams &
Wilkins.
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References
Oermann, M.H., Turner, K. & Carman, M. (2014). Preparing quality
improvement, research, and evidence-based practice manuscripts. Nursing
Economic$, 32(2), 57-69.
Ryan, M. & Rosario, R. (2012). Creating staff confidence in distinguishing
between performance improvement and research studies: A user-friendly
worksheet. Journal of Nursing Administration, 42 (7/8), 369-374.
Shirey, M. R., Hauck, S. L., Embree, J. L., Kinner, T. J., Schaar, G. L., Phillips, L.
A., Ashby, S. R., Swenty, C. F., & McCool, I. A. (2011). Showcasing differences
between quality improvement, evidence-based practice, and research. The
Journal of Continuing Education in Nursing, 42(2), 57-70.
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