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JONA
Volume 37, Number 12, pp 552-557
Copyright B 2007 Wolters Kluwer Health | Lippincott Williams
& Wilkins
T H E J O U R N A L O F N U R S I N G A D M I N I S T R A
T I O N
Organizational Change Strategies for
Evidence-Based Practice
Robin P. Newhouse, PhD, RN, CNA, CNOR
Sandi Dearholt, MS, RN
Stephanie Poe, MScN, RN
Linda C. Pugh, PhD, RNC, FAAN
Kathleen M. White, PhD, RN, CNAA,BC
Evidence-based practice, a crucial competency for
healthcare providers and a basic force in Magnet
hospitals, results in better patient outcomes. The
authors describe the strategic approach to support
the maturation of The Johns Hopkins Nursing

evidence-based practice model through providing
leadership, setting expectations, establishing struc-
ture, building skills, and allocating human and
material resources as well as incorporating the
model and tools into undergraduate and graduate
education at the affiliated university.
Evidence-based practice (EBP) is an essential com-
ponent of professional nursing,1,2 a crucial compe-
tency for healthcare providers,3 and a basic force in
Magnet hospitals4 and results in better patient out-
comes and higher levels of nursing autonomy.5
Fostering EBP within organizations requires strong
infrastructure, including nursing leadership and hu-
man and material resources.6-10 Several organizations
have reported on the use of EBP change models to
assist and mentor individual EBP project teams.11-14
One recent publication discusses the use of a change
model in the context of organizational change,
highlighting the establishment of an EBP committee
that is positioned within the nursing department’s
administrative structure.15 Approaching the imple-
mentation of EBP as an organizational transforma-
tional change frames the approach strategically.16
After the creation and testing of a conceptual
model for EBP,17 a strategic plan was developed to
implement the Johns Hopkins Nursing EBP model
and guidelines (JHN EBP) throughout the organi-
zation. The team knew that the implementation of
EBP would require a substantial change in nursing
culture. The goal was to infuse the use of JHN EBP
into routine practice within each department. This

goal required a number of strategic objectives that
included developing EBP education programs and
Web-based resources, modifying job description cri-
teria to include behavioral outcomes for EBP, defin-
ing the origin of potential question generation, and
building nurse EBP skills and expertise (Table 1).
The EBP program was built through providing lead-
ership, setting expectations, establishing structure,
building skills, and allocating human and mate-
rial resources. The JHN EBP model and tools were
then incorporated into undergraduate and graduate
education at the affiliated university. This article
describes the strategic approach to building infra-
structure to support the maturation of EBP within
an academic medical center.
Leadership
Leadership endorsement was the initial step in
building the EBP program. Nurse administrators
are responsible for managing both human and
552 JONA � Vol. 37, No. 12 � December 2007
Authors’ Affiliations: Assistant Dean, Doctor of Nursing
Practice Studies and Associate Professor, University of
Maryland
School of Nursing, Baltimore, Maryland (Dr Newhouse);
Assistant
Director of Nursing, Neuroscience, and Psychiatry (Ms
Dearholt);
Assistant Director of Nursing, Clinical Quality (Dr Poe),
Nursing
Administration, The Johns Hopkins Hospital, Baltimore,
Maryland;
Professor of Nursing (Dr Pugh), York College of Pennsylvania,

York, Pennsylvania; Associate Professor and Director, Master’s
Program and Interim Director, Doctor of Nursing Practice
Program
(Dr White), The Johns Hopkins University School of Nursing,
Baltimore, Maryland.
Doctor Newhouse was Nurse Researcher at Johns Hopkins
Hospital and Associate Professor at Johns Hopkins University
School of Nursing.
Doctor Pugh was an associate professor at the Johns Hopkins
University School of Nursing.
Corresponding author: Dr Poe, The Johns Hopkins Hospital,
Department of Nursing Administration, 600 N. Wolfe St., ADM
220, Baltimore, MD 21287 ([email protected]).
material resources necessary for the successful
implementation of the EBP program. Leadership
is critical to build organizational readiness for
change.16,18 This nursing department is part of a
highly decentralized organization. A director of
nursing, an administrator, and a physician director
lead each department with responsibility for the
service area. Because of their accountability for
resources, it was essential that the directors of
nursing were committed to the EBP implementa-
tion goals. The strategic plan was approved by

leadership and the governance committees (stan-
dards of care [SOC], standards of practice, nursing
clinical quality improvement, staff education, and
research committees) and was then incorporated
into the committee structure.
Establishing the Structure
To establish a structure for building and sustaining
EBP, a majority of the governance committees were
charged with specific responsibilities. These gover-
nance committees include committee chairs, SOC,
standards of practice, nursing clinical quality
improvement, staff education, and research. Com-
mittee chairs consist of the chairs and cochairs for
each of the governance committees. Committee
chairs drafted EBP committee goals that were
aligned with the purpose of each committee. Each
committee then reviewed and revised or supported
these goals. In addition, the purpose and functions
of each committee were reviewed in light of
the EBP initiative. During implementation, each
Table 1. Strategic Plan to Infuse The Johns Hopkins Nursing
(EBP) Model
Objectives Responsibility
Build local experts through the following Central committees
1. Each functional unit will complete 1 EBP project using The
Johns Hopkins
Nursing EBP Model and Guidelines.
2. Central committee members (research, standard of care,

education, and nursing
clinical quality improvement) will collaborate on choosing the
practice question,
leading the EBP process, recommending the practice changes if
indicated,
assuring that the implementation occurs, and evaluating the
outcome of the project.
3. Functional units will develop a practice question and identify
EBP team members
in consultation with central committee representatives.
4. Functional units will create a plan for staff education, format
selecting from the
options listed below.
Develop EBP education programs EBP core members
Target: trainers
1. Small group rapid cycle or 1-day training
2. Train the trainer competencies (health stream)
Target: staff
Mandatory health stream training is dependent on job
description. EBP core members with
committee approval1. Health stream
Module 1: Introduction (history, definitions, model, and
practice question)
Module 2: Searching evidence (defining terms, sources, and
technique)
Module 3: Evaluating the evidence (rating, summarizing, and
recommending
practice changes)
Module 4: Implementing practice changes

Optional training if desired
2. Health stream plus day practicum
3. One-day workshop by core mentors and trainers scheduled by
functional unit
Develop Web-based resources for all nursing staff to access
EBP core members
1. Model and guidelines (manual)
2. Tools (practice question, rating scales, critique summaries,
project management
guide, and evaluation)
Modify job description criteria to include behavioral outcomes
for EBP Standards of practice
1. Nurse clinician IVobjectives related to module 1
2. Nurse clinician IIM and EVobjectives related to modules 1-3
3. Nurse clinician IIIVparticipation in 1 EBP project per year
(modules 1-4)
Define origin of potential question generation EBP core
members
Problem prone/high-risk clinical processes or diagnosis,
evidence to support the
practice challenged, or high variations in practice or outcomes.
Build EBP competencies Nursing administration/
departments1. Require module 1 for all current registered nurses
(RNs) in 2006.
2. Require module 1 for all newly hired RNs within the first
year of employment.
JONA � Vol. 37, No. 12 � December 2007 553

committee in the governance structure had respon-
sibility for a specific goal (Figure 1). The SOC
committee became responsible for reporting prog-
ress and monitoring outcomes of the EBP initia-
tives within each department. This structure was
important because it infused the responsibility for
EBP across the professional governance commit-
tees, making nurse leaders on the committees
accountable for growing and sustaining the EBP
program. To continue to enhance EBP expertise
and engagement, each department is completing at
least 1 project over a 15-month period.
Developing an EBP Skill Set
One of the most important steps in the plan was to
develop EBP experts that would act as future
mentors. These individuals were to be the primary
champions and facilitators of EBP. They were
members of the governance committees; thus,
incorporating EBP goals into responsibilities as a
committee member was well aligned with moving
the strategic initiative ahead.19
In addition, nurse schedules needed to accom-
modate time away from clinical responsibilities for
initial training and then later to complete the EBP

process. The buy-in from nursing leadership was
essential to support nurse scheduling to meet the
training requirements, provide the needed encour-
agement, and assure that the EBP projects were
focused on an important area for which practice
recommendations were needed.
Development of Material Resources
A number of resources needed to be established to
foster the growth and development of the program.
These resources included the availability of the
JHN EBP model, process, guidelines, and tools in
written and electronic formats. It was also impor-
tant to assure that library, database, and Web
resources were accessible to each nurse.
Training and mentorship were offered in each
department through the committee member men-
tors who had completed initial training. The authors
(core EBP group) were also available for committee
members and teams. Because there is not one
strategy that is always successful, the team planned
multiple strategies for training and education.8 Our
goal to develop EBP skills and competencies
required that we develop a training and education
plan, using several approaches to meet the needs of
the nurses and organization through multimethod
education, demonstration, mentorship, and fellow-
ship. Examples of strategies included rapid cycle
training, a 1-and 2-day seminar approach, multi-
disciplinary groups, completion of projects within
the committee structure, and committee members
mentoring teams in their departments.

In addition to these educational approaches, a
fellowship in EBP was developed and budgeted
through the department of nursing administration.
Two fellowships were awarded through a compet-
itive process that provided salary support for 20
hours per week for 3 months. This opportunity
provided the time needed for the fellows to develop
advanced EBP skills to prepare them to lead EBP
initiatives at the unit, functional unit, and hospital
levels. The first fellow focused on delirium screen-
ing and nursing interventions to decrease the
intensity, frequency, and duration of delirium. Re-
sults of her project were used to provide education
to unit nurses. She also completed her first pub-
lication. The team recommended that the next
fellowship be assigned by the SOC committee to
better align the fellow’s work with the needs of
Figure 1. The shared governance role in the implementation of
evidence-based practice (EBP).
the organization. A protocol was selected in the
ophthalmology department, with the second fellow
facilitating and supporting their EBP process.
An additional resource developed was EBP

assistants who were available on an as-needed basis
for unit projects. These assistants were undergrad-
uate nursing students from local universities. Exam-
ples of the types of support they provided include
running literature searches, retrieving requested
articles, disseminating the team’s evidence summa-
ries, and documenting EBP team meetings. The
salary for these assistants was initially supported
through a small grant from the Maryland Health
Services Cost Review Commission. After a favor-
able evaluation of this resource at the end of the
funding period, EBP assistants were included in
subsequent nursing administration budgets.
Setting Expectations
To incorporate EBP as an expectation of nursing
practice, nursing staff job descriptions were revised
after significant input from the governance com-
mittees, staff, and managers. An example of a
revision is provided in Figure 2. It was important to
construct language that was broad enough to allow
different units to apply the standard to fit their
needs. All indirect care positions are now under
review for incorporating EBP expectations.
A basic Web EBP course was developed in 2005
and implemented as a required competency for
RNs in 2006 to promote understanding of the EBP
program, goal, and resources. The basic compe-
tency education will move from yearly competency
to the nurse orientation curriculum for 2007. Three
additional modules are in development to address
educational needs beyond basic competencies.
Collaborative Strategies: Introduction of

the Model to the School of Nursing
Since the early 1990s, research utilization has been
a major focus in the undergraduate research
courses at Johns Hopkins University School of
Nursing (JHUSON). As the focus changed from
research utilization to EBP and the JHN EBP team
began presenting their model and resources, part of
the implementation plan was to infuse EBP into the
JHUSON. In fall of 2004, a pilot was conducted
with 1 section of the undergraduate research class.
The class used the JHN EBP tools and worked on a
project from a problem identified by nurses at The
Johns Hopkins Hospital. The requirement for an
undergraduate EBP project was revised with full
implementation using the JHN EBP model in the
spring semester of 2005.
At the same time, the master’s program curric-
ulum was being revised. Revisions were driven by
Figure 2. Job descriptions revisions to incorporate evidence-
based practice (EBP) into standard: maintains awareness of
scientific basis for nursing practice.
the belief that the research course should prepare

advanced practice nurses to translate evidence into
the best practices. A new course was developed:
Application of Research to Practice. The skills
demonstrated are essential for the EBP organiza-
tional leader. Two outcomes of this course include
(1) conducting a team EBP project and (2) demon-
strating evidence critique and rating competencies
in an individual state of the sciences paper. The
focus of these assignments can be clinical, admin-
istrative, or educational nursing problems.
Incorporating these changes into the JHUSON
curriculum also required faculty training in the
conceptual underpinnings of the model as well as
the EBP process and available tools. Three members
of the team presented a faculty training seminar,
covering the model, tools, and process. A mock
critique and rating session provided the faculty with
a hands_on experience with the tools and process.
Lessons Learned
The EBP implementation and infusion described in
this article occurred between 2004 and 2006. The
team learned a number of lessons, which include
the importance of leadership support to foster the
strategic plan, the need for flexibility in training
approaches to meet the requirements of the staff,
the necessity of strategic resource planning, the
essential role of mentors, and the need to have a
model and tools available. Seeking synergistic
opportunities to collaborate with academic institu-
tions and students provides a win-win outcome.20
Model and Tool Revisions

We have used the model and guidelines previously
published21 in multiple projects within and outside
the organization. Based on this experience, we have
kept the PET (practice question, evidence, transla-
tion) process in place but have made some modifi-
cations to the tools used for the EBP project (Figure 3)
and further refined the graphic for the conceptual
model (Figure 4). Within the JHN EBP model, EBP
is a problem-solving approach to making clinical,
educational, and administrative decisions that
combines the best available scientific evidence with
the best available practical evidence. The process
takes internal and external influences on practice
into consideration and requires the nurse to use
critical thinking when applying the evidence.17
Future Directions
The JHN EBP has evolved into a mature phase of
development. To move to the next stage, we need
to develop and mentor additional EBP experts,
expand the use of the model and tools, and
continue to make revisions based on our experi-
ences. We have planned additional training for staff
and mentors, continued fellowships, and added a
seminar on publication to help nurses publish the
results their EBP projects. A book which includes
the JHN EBP model and tools is in press.22
Figure 3. Evidence-based practice tools.
Figure 4. The Johns Hopkins Nursing Evidence-based Practice
Conceptual Model.

We continue to support the strategic plan for
our organization to facilitate the infusion of EBP
into every component of nursing practice, provid-
ing leadership, mentorship, and resources. The
plan must be flexible and iterative to incorporate
lessons learned, to adapt the process to meet the
needs of the nurses, and to continue to develop
opportunities to engage and build skills for nurses.
References
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2. American Nurses Association. Nursing: Scope and Stan-
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Association; 2004.
3. Committee on the Health Professions Education Summit
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eds. Health Professions Education: A Bridge to Quality.
Washington, DC: The National Academies Press; 2003.

4. American Nurses Credentialing Center. Magnet Recognition
Program. Silver Spring, MD: American Nurses Credential-
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5. Newhouse RP. Examining the support for evidence-based
nursing practice. J Nurs Adm. 2006;36(7-8):337-340.
6. Scott-Findlay S, Golden-Biddle K. Understanding how
organizational culture shapes research use. J Nurs Adm.
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7. Stetler CB. Role of the organization in translating research
into evidence-based practice. Outcomes Manag. 2003;7(3):
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8. NHS Centre for Reviews and Dissemination, University of
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The Royal Society of Medicine Press Limited. 1999;5(1).
http://www.york.ac.uk/inst/crd/ehc51.pdf. Accessed October
17, 2007.
9. Fineout-Overholt E, Levin RF, Melnyk BM. Strategies for
advancing evidence-based practice in clinical settings. J N Y
State Nurses Assoc. 2004-2005;35(2):28-32.
10. Fineout-Overholt E, Melnyk BM. Building a culture of best
practice. Nurse Leader. 2005;3(6):26-30.
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13. Kavanagh D, Connolly P, Cohen J. Promoting evidence-
based practice: implementing the American Stroke Associa-
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14. Dickinson D, Duffy A, Champion S. Research in brief.
J Psychiatr Ment Health Nurs. 2004;11(1):117-119.
15. Mohide EA, Coker E. Toward clinical scholarship: promot-
ing evidence-based practice in the clinical setting. J Prof
Nurs. 2005;21(6):372-379.
16. Newhouse RP. Creating infrastructure supportive of
evidence-
based nursing practice: leadership strategies. Worldviews
Evid Based Nurs. 2007;4(1):21-29.
17. Newhouse R, Dearholt S, Poe S, Pugh LC, White K. The
Johns Hopkins Nursing Evidence-Based Practice Model.
Baltimore, MD: Johns Hopkins University School of Nurs-
ing, The Johns Hopkins Hospital; 2005.
18. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou
O.
Diffusion of innovations in service organizations: systematic

review and recommendations. Milbank Q. 2004;82(4):581-629.
19. Dearholt S, White K, Newhouse RP, Pugh LC, Poe S.
Making
the vision reality: educational strategies to develop evidence-
based practice mentors. J Nurses Staff Dev. In press.
20. Newhouse RP. Collaborative synergy: practice and academic
partnerships in evidence-based practice. J Nurs Adm. In press.
21. Newhouse RP, Dearholt S, Poe S, Pugh LC, White KM.
Evidence based practice: a practical approach to implemen-
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22. Newhouse RP, Dearholt S, Poe S, Pugh LC, White K. Johns
Hopkins Nursing Evidence-based Practical Model and Guide-
lines. Sigma Theta Tau International: Indianapolis, IN.
Sustaining Evidence-Based Practice Through
Organizational Policies and an Innovative Model
The team adopts the Advancing Research and Clinical
Practice Through Close Collaboration model.
This is the 12th and last article in a series from the Arizona
State University College of Nursing and Health Innovation’s
Center for the Advancement of Evidence-Based Practice.
Evidence-based practice (EBP) is a problem-solving approach to

the delivery of health care that integrates the best evidence from
studies and patient care data with clinician expertise and
patient preferences and values. When it’s delivered in a context
of caring and in a supportive organizational culture, the
highest quality of care and best patient outcomes can be
achieved. The complete EBP series is available as a collection
on our Web site; go to www.ajnonline.com and click on
Collections.
In July’s evidence-based prac-tice (EBP) article, Rebecca R.,
Carlos A., and Chen M. eval-
uated the outcomes of their rapid
response team (RRT) implemen-
tation project. Their findings in-
dicated that a significant decrease
in one outcome, code rates outside
the ICU, had occurred after im-
plementation of the RRT. This
promising finding, together with
many other considerations—such
as organizational readiness; clini-
cian willingness; and a judicious
weighing of all the costs, benefits,
and outcomes—encouraged the
EBP team to continue with plans
to roll out the RRT protocol
throughout the entire hospital
system. They also began to work
on presentations and publications
about the project so that others
could learn from their experience
and implement similar interven-
tions to improve patient outcomes.
USING EVIDENCE TO INFORM
ORGANIZATIONAL POLICY

Because Rebecca, Carlos, and Chen
are concerned about whether the
implementation of an RRT can be
sustained over time in their hospi-
tal, they want to take the neces-
sary steps to create a hospital- wide
RRT policy. Therefore, they make
an appointment with their hospi-
tal’s director of policies and pro-
cedures, Maria P., to share the
outcomes data they’ve gathered
from their project and to discuss
the project’s success so far. Maria
is impressed by the rigor of the
team’s sequential EBP process
and the systematic way in which
they’ve gathered the outcomes
data. She reminds them that the
measurement of outcomes (inter-
nal evidence) plus rigorous re-
search (external evidence) result
in the best evidence-based orga-
nizational policies to guide the
high est quality of care in health
care institutions.
Maria volunteers to assist the
team in writing a new evidence-
based policy to support having an
RRT in their hospital. She suggests
that each recommendation in the
policy be supported by evidence.
Maria explains that once the pol-

icy is written, it needs to be ap-
proved by the hospital-wide policy
committee, representing all of the
health disciplines. Maria empha-
sizes that transdisciplinary health
care professionals and administra -
tors should routinely be involved
when planning and implementing
evidenced-based organizational
policies. She also reminds the EBP
team that translating evidence and
evidence-based organizational pol-
icies into sustainable routine clin-
ical practices remains a major
challenge for health care systems.
The new RRT policy written by
Rebecca, Carlos, and Chen with
Maria’s help is approved by the
hospital-wide policy committee
within three months. Now the
By Bernadette Mazurek Melnyk,
PhD, RN, CPNP/PMHNP, FNAP,
FAAN, Ellen Fineout-Overholt, PhD,
RN, FNAP, FAAN, Lynn Gallagher-
Ford, MSN, RN, NE-BC, and Susan
B. Stillwell, DNP, RN, CNE, ANEF
[email protected] AJN ▼ September 2011 ▼ Vol. 111, No. 9 57
It only takes one passionate, committed

person to spearhead a team vision to
improve care for patients and their families.
http://www.ajnonline.com
challenge for the team is to work
with clinicians across the hospital
system to implement it. The EBP
team schedules a series of presen-
tations throughout the hospital
to introduce the new RRT policy.
They rotate the days and times of
this in-service to capture as many
direct care clinicians as possible.
To ensure that all clinicians are
educated on the new policy, a da-
tabase is created to track in-ser-
vice attendees, and each hos pital
unit is asked to appoint a volun-
teer to deliver the presentation to
any clinicians who missed it. Post-
ers are created and buttons de-
signed as visual triggers to remind
staff to implement the new policy.
Throughout this process, the
EBP team learned that dissemi-
nation of evidence alone doesn’t
typ ically lead clinicians to make
a sustainable change to EBP, and
they were impressed by how im-
portant it was to have unit-based
champions reinforce the new pol-

icy.1 They also learned that it’s
critical to have an organizational
culture that supports EBP (such as
evidence-based decision making
in tegrated into performance ex-
pectations, up-to-date resources
and tools, ongoing EBP knowledge
and skills-building workshops,
and EBP mentors at the point of
care) in order for clinicians to con-
sistently deliver evidence-based
care.2
Since the process they followed
worked so well, the team believes
that their hospital needs to adopt
a model to guide and reinforce
the creation of a culture to sus-
tain the EBP approach they had
initiated through this project.
They review several EBP process
and system integration models
and decide to adopt the Advanc-
ing Research and Clinical Prac-
tice Through Close Collaboration
(ARCC) model because its key
strategy to sustain evidence-based
care is the presence of an EBP
mentor (a clinician with advanced
knowledge of EBP, mentorship,
and individual as well as organi-
zational change). With Carlos’s
success as an expert EBP mentor,
and the mentorship model work-
ing so well, they believe that de-

veloping a cadre of EBP mentors
system-wide is key to the ongoing
58 AJN ▼ September 2011 ▼ Vol. 111, No. 9 ajnonline.com
Potential Strengths
Philosophy of EBP
(paradigm is system-wide)
Presence of EBP mentors
and champions
Administrative support
Clinicians’ beliefs about
the value of EBP and
ability to implement the
EBP processa
Identification of
strengths and major
barriers to EBP
implementation
EBP
implementationa, b
Decreased
hospital
costs
Potential Barriers

Lack of EBP
mentors and
champions
Inadequate EBP
knowledge and
skills
Lack of EBP
valuing
Implementation of
ARCC strategies
Interactive
EBP skills building
EBP rounds and
journal clubs
Improved
patient
outcomes
Nurse/clinician
satisfaction
Cohesion
Intent to
leave
Turnover

Development
and use of EBP
mentors
Assessment of
organizational
culture and
readiness for EBP
a
Figure 1. The ARCC Model for System-Wide Implementation
and Sustainability of EBP
ARCC = Advancing Research and Clinical Practice Through
Close Collaboration; EBP = evidence-based practice.
a
Scale developed.
b
Based on the EBP paradigm and using the EBP process.
©
2
00
5,
M
el
ny
k

an
d
Fi
ne
ou
t-O
ve
rh
ol
t.
that this model be adopted, not
only for the nursing department,
but for all disciplines throughout
the organization.
THE EBP JOURNEY HAS JUST BEGUN
This series presented a case in-
volving a hypothetical medical–
surgical nurse and her colleagues
to illustrate how EBP can be suc-
cessfully implemented to improve
key patient outcomes. It’s impor-
tant that the process start with
an ongoing spirit of inquiry, and
that nurses always question the
evidence behind the care we pro-
vide and never settle for the sta-
tus quo. Never forget that it only

takes one passionate, committed
person to spearhead a team vi-
sion to improve care for patients
and their families. It also takes
persistence through the “charac-
ter builders” that are sure to
appear as the vision comes to
fruition.
Although the EBP team has
successfully completed their RRT
implementation project and its
incorporation as a hospital-wide
policy, their EBP journey has just
be gun. In fact, only days after the
project’s completion, Rebecca
asked Carlos another great PICOT
question: “In critically ill patients,
how does early ambulation com-
pared with delayed ambulation
affect ventilator-associated pneu-
monia in the ICU?” Carlos looked
at her and replied, as a great men -
tor does, “I will help you search
for the evidence and we will find
and organizational culture change.
These individuals, whether expert
system-wide mentors, advanced
practice mentors, or peer mentors,
are focused on helping point-of-
care clinicians to use and sustain
EBP and to conduct EBP imple-
mentation, quality improvement,
and outcomes management proj-
ects. When clinicians work with

EBP mentors, their beliefs about
the value of EBP and their ability
to implement it increase, and this
is followed by a greater achieve-
ment of evidence-based care.4
The ARCC model contends that
greater implementation of EBP
results in higher job satisfaction,
lower turnover rate, and better
patient outcomes. A series of
studies now support the empiri-
cal relationships in the ARCC
model.4-8
The ARCC model has been
and continues to be implemented
in hospitals and health care sys-
tems across the country with ex-
cellent results in quality of care and
patient outcomes. Valid and reli-
able instruments, such as the EBP
Beliefs and EBP Implementation
scales,6 are used to measure key
constructs in the model and, to-
gether with organizational culture
and readiness for EBP, help to de-
termine the model’s effectiveness.6
The EBP team discusses how
all the elements of the ARCC
model are an excellent fit for their
organization. They decide to make
a recommendation to the Shared
Governance Steering Committee

implementation and sustainabil-
ity of EBP in their organization.
SUSTAINING AN EBP CULTURE WITH THE
ARCC MODEL
In reviewing the ARCC model,
the EBP team finds that its aim is
to provide hospitals and health
care systems with an organized
conceptual framework to guide
system-wide implementation and
sustainability of EBP for the pur-
pose of improving quality of care
and patient outcomes. In addition,
this model can be used to achieve
a “high reliability” organization
(one that delivers safe and high-
quality care), decrease costs, and
improve clinicians’ job satisfaction.
Four assumptions are basic to the
ARCC model3:
• Both barriers to and facilitators
of EBP exist for individuals and
within health care systems.
• Barriers to EBP must be re-
moved or mitigated and facili-
tators put in place in order for
individuals and health care sys -
tems to implement EBP as a
standard of care.
• For clinicians to change their
practices to be evidence based,
both their beliefs about the

value of EBP and their confi-
dence in their ability to imple-
ment it must be strengthened.
• An EBP culture that includes
EBP mentors is necessary in
order to advance and sustain
EBP in individuals and health
care systems.
The first step in the ARCC
model is to assess the organiza-
tion’s culture and readiness for EBP
(see Figure 1). From that assess-
ment, the strengths and limita tions
of implementing EBP within the
organization can be identified. The
key implementation strategy in the
ARCC model is the development
of a cadre of EBP mentors, who
are typically advanced practice
nurses or clinicians with in-depth
knowledge of and skills in EBP
and in individual behavior change
[email protected] AJN ▼ September 2011 ▼ Vol. 111, No. 9 59
Developing a cadre of EBP mentors
system-wide is key to the ongoing
implementation and sustainability of
EBP in an organization.

Wiley-Blackwell; Sigma Theta Tau;
2010. p. 169-84.
4. Melnyk BM, et al. Nurses’ perceived
knowledge, beliefs, skills, and needs
regarding evidence-based practice: im -
plications for accelerating the para-
digm shift. Worldviews Evid Based
Nurs 2004;1(3):185-93.
5. Levin RF, et al. Fostering evidence-
based practice to improve nurse and
cost outcomes in a community health
setting: a pilot test of the advancing
research and clinical practice through
close collaboration model. Nurs Adm
Q 2011;35(1):21-33.
6. Melnyk BM, et al. The evidence-
based practice beliefs and implemen-
tation scales: psychometric properties
of two new instruments. Worldviews
Evid Based Nurs 2008;5(4):208-16.
7. Melnyk BM, et al. Correlates among
cognitive beliefs, EBP implementa-
tion, organizational culture, cohesion
and job satisfaction in evidence-based
practice mentors from a community
hospital system. Nurs Outlook 2010;
58(6):301-8.
8. Wallen GR, et al. Implementing
evidence-based practice: effectiveness
of a struc tured multifaceted mentor-

ship programme. J Adv Nurs 2010;
66(12):2761-71.
Practice. Contact author: Berna dette
Mazurek Melnyk, [email protected]
The authors have disclosed no potential
conflicts of inter est, financial or other-
wise.
REFERENCES
1. Melnyk BM, Wiliamson KM. Using
evidence-based practice to enhance
organizational policies, healthcare qual -
ity, and patient outcomes. In: Hinshaw
AS, Grady PA, editors. Shaping health
policy through nursing research. New
York: Springer Publishing Company;
2011. p. 87-98.
2. Melnyk BM, Fineout-Overholt E.
Evidence-based practice in nursing
and healthcare: a guide to best prac-
tice. Philadelphia: Wolters Kluwer
Health/Lippincott Williams and Wil-
kins; 2011.
3. Melnyk BM, Fineout-Overholt E.
ARCC (Advancing Research and Clini-
cal prac tice through close Collabora-
tion): a model for system-wide
implementation and sustainability of
evidence-based practice. In: Rycroft-
Malone J, Bucknall T, editors. Models
and frame works for implementing
evidence-based practice: linking evi-

dence to action. Oxford; Ames, IA:
the answer to your question—
because EBP, not practices steeped
in tradition, is the only way we
do it here!” ▼
Bernadette Mazurek Melnyk is associate
vice president for health promotion, uni-
versity chief wellness officer, and dean of
The Ohio State University College of Nurs -
ing in Columbus, where Lynn Gallagher-
Ford is director of Transdisciplinary
Evidence-Based Practice and Clinical
Innovation. Ellen Fineout-Overholt is
dean of Professional Studies and chair of
the Department of Nursing at East Texas
Baptist University in Mar shall, TX.
Susan B. Stillwell is clinical professor and
associate director of the Center for the
Advancement of Evidence-Based Practice
at Arizona State Univer sity in Phoenix.
At the time this article was written, Ber-
nadette Mazurek Melnyk was dean and
distinguished foundation professor of
nursing in the College of Nurs ing and
Health Innovation at Arizona State Uni-
versity, where Ellen Fineout-Overholt was
clinical pro fessor and director, and Lynn
Gallagher-Ford was clinical assistant pro-
fessor and assistant director, of the Center
for the Advancement of Evidence-Based

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Implementing an Evidence-Based Practice Change
Beginning the transformation from an idea to reality.
This is the ninth article in a series from the Arizona State
University College of Nursing and Health Innovation’s Cen-
ter for the Advancement of Evidence-Based Practice. Evidence-
based practice (EBP) is a problem-solving approach to
the delivery of health care that integrates the best evidence from
studies and patient care data with clinician expertise
and patient preferences and values. When delivered in a context
of caring and in a supportive organizational culture,
the highest quality of care and best patient outcomes can be
achieved.
The purpose of this series is to give nurses the knowledge and
skills they need to implement EBP consistently, one
step at a time. Articles will appear every other month to allow
you time to incorporate information as you work to -
ward implementing EBP at your institution. Also, we’ve
scheduled “Chat with the Authors” calls every few months to
provide a direct line to the experts to help you resolve
questions. Details about how to participate in the next call will
be published with May’s Evidence-Based Practice, Step by Step.
In January’s evidence-based prac tice (EBP) article, Rebe -cca
R., our hypothetical staff
nurse, Carlos A., her hospital’s
ex pert EBP mentor, and Chen
M., Rebecca’s nurse colleague,
began to develop their plan for

implementing a rapid response
team (RRT) at their institution.
They clearly identified the pur-
pose of their RRT project, the
key stakeholders, and the vari-
ous outcomes to be measured,
and they learned their internal
re view board’s requirements for
re viewing their pro posal. To de-
termine their next steps, the team
consults their EBP Implementa-
tion Plan (see Figure 1 in “Fol-
lowing the Evidence: Plan ning
for Sustainable Change,” Jan -
uary). They’ll be working on
items in checkpoints six and
seven: specif ically, engaging the
stakeholders, getting administra-
tive support, and preparing for
and conducting the stakeholder
kick-off meeting.
ENGAGING THE STAKEHOLDERS
Carlos, Rebecca, and Chen reach
out to the key stakeholders to tell
them about the RRT project by
meeting with them in their offices
or calling them on the phone. Car -
los leads the team through a dis-
cussion of strategies to promote
success in this critical step in the
implementation process (see Strat -
egies to Engage Stakeholders). One
of the strategies, connect in a col-
laborative way, seems espe cially

applicable to this project. Each
team member is able to meet with
a stakeholder in person, fill them
in on the RRT project, describe
the purpose of an RRT, discuss
their role in the project, and an -
swer any questions. They also tell
each stakeholder about the initial
project meeting to be held in a few
weeks.
In anticipation of the stake-
holder kick-off meeting, Carlos
and the team discuss the fun -
damen tals of preparing for an
im portant meeting, such as how
to set up an agenda, draft key doc-
uments, and conduct the meet -
ing. They begin to discuss a time
and date for the meeting. Carlos
suggests that Rebecca and Chen
meet with their nurse manager
to up date her on the project’s
pro gress and request her help in
sched uling the meeting.
SECURING ADMINISTRATIVE SUPPORT
After Rebecca updates her man-
ager, Pat M., on the RRT pro ject,
Pat says she’s impressed by the
team’s work to date and of fers
to help them move the project
forward. She suggests that, since
they’ve already invited the stake-
holders to the upcoming meet ing,

they use e-mail to communicate
the meeting’s time, date, and
place. As they draft this e-mail
together, Pat shares the follow -
ing tips to im prove its effective-
ness:
• communicate the essence and
importance of the e-mail in the
subject line
• write an e-mail that’s engaging,
but brief and to the point
• introduce yourself
• explain the project
54 AJN ▼ March 2011 ▼ Vol. 111, No. 3 ajnonline.com
Strategies to Engage Stakeholders
• Spend time and effort building trust.
• Understand stakeholders’ interests.
• Solicit input from stakeholders.
• Connect in a collaborative way.
• Promote active engagement in establishing
metrics and outcomes to be measured.
By Lynn Gallagher-Ford, MSN, RN, NE-BC, Ellen
Fineout-Overholt, PhD, RN, FNAP, FAAN, Bernadette
Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP,
FAAN, and Susan B. Stillwell, DNP, RN, CNE

• welcome the recipients to the
project and/or team and invite
them to the meeting
• explain why their attendance
is critical
• request that they read certain
materials prior to the meeting
(and attach those documents
to the e-mail)
• let them know whom to con-
tact with questions
• request that they RSVP
• thank them for their partici-
pation
Before they send the e-mail (see
Sample E-mail to RRT and Stake-
holders), the team wants to make
sure they don’t miss anyone, so
they review and include all of the
RRT members and stake holders.
They realize that it’s im portant to
invite the manager of each of the
stakeholders and disciplines rep-
resented on the RRT and ask
them to also bring a staff represen-
tative to the meeting. In addition,
they copy the administrative di rec -
tors of the stakeholder depart-
ments on the e-mail to en sure that
they’re fully aware of the project.

PREPARING FOR THE KICK-OFF
MEETING
The group determines that the
draft documents they’ll need to
prepare for the stakeholder kick-
off meeting are:
• an agenda for the meeting
• the RRT protocol
• an outcomes measurement plan
• an education plan
• an implementation timeline
• a projected budget
To expedite completion of the doc-
uments, the team divides them up
among themselves. Chen volun-
teers to draft the RRT protocol
and outcomes measurement plan.
Carlos assures her that he’ll guide
her through each step. Rebecca
decides to partner with her unit ed-
ucator to draft the education plan.
Carlos agrees to take the lead in
drafting the meeting agenda, im -
plementation timeline, and pro-
jected budget, but says that since
this is a great learning opportu-
nity, he wants Rebecca and Chen
to be part of the drafting process.
Drafting documents. Carlos
tells the team that the purpose of
a draft is to initiate discussion and
give the stakeholders an oppor tu -
nity to have input into the final

prod uct. All feedback is a positive
sign of the stakeholders’ involve-
ment, he says, and shouldn’t
be per ceived as criticism. Carlos
also offers to look for any tem-
plates from other EBP projects
that may be helpful in drafting
the documents. He tells Rebecca
[email protected] AJN ▼ March 2011 ▼ Vol. 111, No. 3 55
Sample E-mail to RRT and Stakeholders
To: ICU Nurse Manager, 3 North Nurse Manager, Respiratory
Therapy Director, Medical Director of ICU, Director of
Acute Care NP Hospitalists, Director of Spirituality Department
cc: EBP Council Chair, VP Nursing, VP Medical Affairs, ICU
Nursing Director, Medical–Surgical Nursing Director,
Finance Department Director, Communications Department
Director, Risk Management Director, Education Department
Director, HIMS (Medical Records) Director,
Quality/Performance Improvement Director, Clinical
Informatics Director,
Pharmacy Director
Subject: Invitation to the Rapid Response Project Stakeholder
Kick- off Meeting
Good afternoon. I would like to introduce myself. My name is
Rebecca R. I am a staff nurse III on the 3 North medical–
surgical unit. You have either spoken with me or with one of my
colleagues, Carlos A. or Chen M., about an important
evidence-based initiative that will help improve the quality of
care for our patients. The increasing patient acuity on our
unit and throughout the hospital, and the frequent need for
patients to be transferred to the ICU, prompted us to ask

important questions about patient outcomes. For the past few
months, Carlos, Chen, and I have been investigating how
our hospital can reduce the number of codes, particularly
outside the ICU. We have conducted a thorough search for
and appraisal of current available evidence, which we would
like to share with you.
Our team and our managers would like to invite you to
participate in a kick-off meeting to discuss an exciting
evidence-based initiative to improve the quality of patient care
in our hospital. The meeting will be held on March 1,
2011, at 10 am in the Innovation Conference Room on the 2nd
floor. It is very important that you attend this meeting
as you have been identified as a critical participant in this
project. We need your input and support as we move for-
ward. So please plan to attend the meeting or send a
representative. To ensure that we have sufficient materials for
the
meeting, please RSVP to Mary J., unit secretary on 3 North.
I want to thank you in advance for your help with and support
of this project. I look forward to seeing you at the
meeting. If you have any questions, please feel free to contact
me or any of the RRT project team members.
Rebecca R. and the RRT Project Team
RRT Protocol Draft for Review
Current evidence supports the effectiveness of an RRT in
decreasing adverse events in patients who exhibit specific
clinical parameters.
Evidence-based recommendations include that RRTs should be

available on general units of hospitals, 24 hours a day and seven
days
a week, staffed by intensive care clinicians, and activated based
on established clinical criteria. The RRT serves a dual purpose
of pro-
viding both early intervention care to at-risk patients and
education in recognizing and managing these patients to clin
ical staff.
The RRT is available to respond to and assist bedside staff in
caring for patients who develop signs or symptoms of clinical
deterio-
ration.
RRT Members
RRT members are all ACLS certified. They include:
Team Leader: Acute Care NP Hospitalist (credentialed in
advanced procedures)
Team Members: ICU RN
Respiratory Therapist (trained in intubation)
Physician Intensivist (ICU MD on call and available to the
RRT)
Hospital Chaplain
Initiation of RRT Consult
An RRT consult can be initiated by any bedside clinician.
Consults should be initiated based on the following patient
status criteria.
RRT Consult Initiation Criteria
Pulmonary
Ventilation: Color change (pale, dusky, gray, or blue)

Respiratory distress: RR < 10 or > 30 breaths/min, or
Unexplained dyspnea, or
New-onset difficulty breathing, or
Shortness of breath
Cardiovascular
Tachycardia: Unexplained > 130 beats/min for 15 mins
Bradycardia: Unexplained < 50 beats/min for 15 mins
Blood pressure: Unexplained SBP < 90 or > 200 mmHg
Chest pain: Complaint of nontraumatic chest pain
Pulse oximetry: < 92% SpO2
Perfusion: UOP < 50 cc/4 hr
Neurologic
Seizures: Initial, repeated, or prolonged
Change in mental status: Sudden decrease in LOC with normal
blood sugar
Unexplained agitation for > 10 min
New- onset limb weakness or smile droop
Sepsis
Clinical indicators of sepsis: Temperature > 38ºC
HR > 90 beats/min
RR > 20 breaths/min
WBC > 12,000, < 4,000

Nurse’s concern about overall deterioration in patient’s
condition without any of the above criteria.
Scope of the RRT
The RRT can be expected to perform any/all of the following
interventions:
Nasopharyngeal/oropharyngeal suctioning
Oxygen therapy
Initiation of CPAP
Initiation of nebulized medications
Intravenous fluid bolus(es)
Intravenous fluid bolus(es) with medication
CPR
The RRT can be expected to perform any/all of the following
invasive procedures:
Endotracheal intubation
Intravenous line insertion
Intraosseous line insertion
Arterial line insertion
Central line insertion
RRT Consult Procedure
1. Assess patient relative to the above criteria.
2. If any of the above criteria are identified, initiate the RRT
consult by calling 5-5555. The operator will request the caller’s
location,
the patient’s name, the patient’s location, and the reason for
RRT activation. This call will generate both pages to the RRT

members
and an overhead announcement.
3. The RRT will arrive within five minutes (or less) of the call.
4. Be prepared to provide the RRT with appropriate
information about the patient using the SBAR communication
method. (See stan-
dardized communication protocol no. 7.)
5. While awaiting the arrival of the RRT, consider initiating
any/all of the following actions:
• Call for a colleague to help you
• Set up oxygen apparatus
• Set up suction apparatus
• Call for the code cart to be brought to the area
• Communicate with the patient’s family (if present); tell them
what you’re doing and why and that someone will be here
shortly
to help them
• Obtain proper documentation tools to be used during the RRT
consult
RRT Arrival
When the RRT arrives:
1. Provide information as indicated above.
2. Participate in the care of your patient and remain with the
patient and the RRT.
3. Assist the RRT as needed.
4. Document activities, interventions performed, and patient
responses to interventions.
5. Work with the chaplain to ensure that the patient’s family is
informed of the situation at intervals.
6. Assist in arranging for transfer of the patient to a higher
level of care if indicated.

7. Provide a detailed report to the nurse accepting the patient
on the receiving unit, utilizing the SBAR communication
method.
ACLS = advanced cardiac life support; cc = cubic centimeters;
CPAP = continuous positive airway pressure; CPR =
cardiopulmonary resusci-
tation; hr = hours; HR = heart rate; ICU = intensive care unit;
LOC = level of consciousness; MD = medical doctor; min =
minute; mmHg =
millimeters of mercury; NP = nurse practitioner; RN =
registered nurse; RR = respiratory rate; RRT = rapid response
team; SBAR = situation-
background-assessment-recommendation; SBP = systolic blood
pressure; SpO2 = arterial oxygen saturation; UOP = urine
output; WBC = white
blood count.
REFERENCES
1. Choo CL, et al. Rapid response team: a proactive strategy in
managing haemodynamically unstable adult patients in the acute
care hospitals.
Singapore Nursing Journal 2009;36(4);17-22.
2. Winters BD, et al. Rapid response systems: a systematic
review. Crit Care Med 2007;35(5):1238-43.
3. Hillman K, et al. Introduction of the medical emergency
team (MET) system: a cluster-randomised controlled trial.
Lancet 2005;365(9477):2091-7.
4. Sharek PJ, et al. Effect of a rapid response team on hospital-
wide mortality and code rates outside the ICU in a children’s
hospital. JAMA 2007;
298(19):2267-74.
5. Mailey J, et al. Reducing hospital standardized mortality rate
with early interventions. J Trauma Nurs 2006;13(4):178-82.

6. Dacey MJ, et al. The effect of a rapid response team on
major clinical outcome measures in a community hospital. Crit
Care Med 2007;35(9):
2076-82.
7. Benson L, et al. Using an advanced practice nursing model
for a rapid response team. Jt Comm J Qual Patient Saf
2008;34(12):743-7.
8. Hatler C, et al. Implementing a rapid response team to
decrease emergencies. Medsurg Nurs 2009;18(2):84-90, 126.
9. Bader MK, et al. Rescue me: saving the vulnerable non-ICU
patient population. Jt Comm J Qual Patient Saf 2009;35(4):199-
205.
10. DeVita MA, et al. Use of medical emergency team responses
to reduce cardiopulmonary arrests. Qual Saf Health Care
2004;13(4):251-4.
and Chen that he’s confident they’ll
do a great job and shares his ex -
cite ment at how the team has pro-
gressed in planning an EBP practice
change.
RRT protocol. Chen starts to
draft the RRT protocol using one
of the hospital’s protocols as a
tem plate for the format, as well
as definitions and examples of
protocols, policies, and proce-
dures from other organizations
and the literature. She returns to
the articles from the team’s origi-

nal literature search (see “Critical
Appraisal of the Evidence: Part I,”
July 2010) to see if there is infor-
mation, previously appraised, that
will be helpful in this current step
in the process. She recalls that the
team had set aside some articles
be cause they didn’t directly an -
swer the PICOT question about
whether to implement an RRT,
but they did have valuable infor-
mation on how to implement an
RRT. In reviewing these articles,
Chen selects one that’s a review
of the literature, though not a
sys tematic review, that includes
many examples of RRT member-
ship rosters and protocols used
in other hospitals, and which
will be help ful in drafting her
RRT protocol document.1 Chen
includes this ex pert opinion ar-
ticle be cause the informa tion it
contains is consistent with the
higher-level evidence already
being used in the project. Using
both higher and lower levels of
evidence, when appropriate, al -
lows the team to use the best infor -
mation available in formulating
their RRT protocol.
As she writes, Chen discovers
that their hospital’s protocols and
other practice documents don’t in -

clude a section on supporting evi-
dence. Knowing that evidence is
critically important to the RRT
pro tocol, she discusses this with the
clinical practice council represen-
tative from her unit who advises
her to add the section to her draft
document. He promises to present
this issue at the next coun cil meet -
ing and obtain the council’s ap -
proval to add an evidence section
to all future practice documents.
Chen reviews the finished product
before she submits it for the team’s
review (see RRT Protocol Draft
for Review1-10).
Outcomes measurement plan.
Based on the appraised evidence
and the many discussions Rebe -
cca and Chen have had about it,
Chen drafts a document that lists
the outcomes the team will mea-
sure to demonstrate the success of
their project, where they’ll ob tain
this information, and who will
gather it (see Table 1). In draf ting
this plan, Chen realizes that they
don’t have all the information
they need, and she’s concerned
that they’re not ready to move
for ward with the stakeholder
kick- off meeting. But when Chen
calls Carlos and shares her con-
cern, Car los reminds her that the

document is a draft and that the
re quired information will be ad -
dressed at the meeting.
Education plan. Rebecca
reaches out to Susan B., the clin ical
educator on her unit, and requests
her help in drafting the education
plan. Susan tells Rebe cca how much
Table 1. Plan for Measuring RRT Success (Draft for Discussion)
Outcome Measurement Source/Owner
CRO • Codes outside of the ICU • EMR
Mortality rates:
HMR and NIM
• Hospital mortality rates by unit • Discuss at meeting
UICUA • ICU admissions
• EMR; ICU admissions database; check
box needed to indicate planned and
unplanned
Return on RRT investment
(cost of RRT compared with savings
due to RRT)
1. Cost of RRT
• Personnel
• Supplies

2. Savings due to RRT
• Cost of UICUA
• Number of UICUA prevented
• RRT personnel cost/hour
• UICUA cost/day
• LOS for average UICUA
• Number of UICUA prevented
• Billing data
• RRT response time and end time as re
corded on the RRT data documentation tool
• Billing data
• Disposition of RRT call as recorded on the
RRT data documentation tool
CRO = code rates outside the ICU; EMR = electronic medical
record; HMR = hospital-wide mortality rates; ICU = intensive
care unit;
LOS = length of stay; NIM = non-ICU mortality; RRT = rapid
response team; UICUA = unplanned ICU admissions.
she enjoys the op portunity to work
collaboratively with staff nurses on
education pro jects and how happy
she is to see an EBP project being
implemented. Rebecca shares her

RRT project folder (containing all
the informa tion relative to the pro-
ject) with Susan, focusing on the
education about the project she
thinks the staff will need. Susan
commends the team for its efforts,
as a good deal of the necessary
work is al ready done. She asks
Rebecca to clarify both the ulti-
mate goal of the project and what’s
most im por tant to the team about
its rollout on the unit. Rebecca
thoughtfully responds that the
ultimate goal is to ensure that
patients re ceive the best care possi-
ble. What’s most im portant about
its rollout is that the staff sees the
value of an RRT to the patients
and its positive impact on their
own workload. She adds that it’s
im portant to her that the project
be conducted in a way that feels
pos itive to the staff as they work
to ward sustain able changes in
their practices.
Susan and Rebecca discuss
which clinicians will need edu -
cation on the RRT. They plan to
use a variety of mechanisms, in -
clud ing in-services, e-mails, news-
letters, and flyers. From their
conversation, Susan agrees to
draft an education plan using a
template she developed for this

purpose. The template prompts
her to put in key elements for
planning an education program:
learner objectives, key content,
methodology, faculty, materials,
time frame, and room location.
Susan fills the template with in-
formation Rebecca has given her,
adding information she knows
already from her expe rience as
an educator. When Rebecca and
Susan meet to re view the plan,
Rebecca is amazed to see how
their earlier conversation has
been transformed into a com-
prehensive document (see the
Education Plan for RRT Imple-
mentation at http://links.lww.
com/AJN/A19).
Agenda and timeline. The
team meets to draft the meeting
agenda, implementation timeline,
and budget. Carlos explains the
purposes of a meeting agenda: to
serve as a guide for the participants
and to promote productivity and
efficiency. They draft an agenda
that includes the key issues to be
shared with the stakeholders as
well as time for questions, feed-
back, and discussion (see the
Rapid Response Team Kick-off
Meeting Agenda at http://links.
lww.com/AJN/A20).

Carlos describes how the time-
line creates a structure to guide
Table 3. RRT Project Budget Draft (Draft for Discussion)
Annual Costs
Item Projected Cost/Unit No. Units
Needed
Cost/Year Cost Center Approval
Needed
Notes:
RRT pagers $30/month 8/month $2,880 Administration VP
Nursing
Data
collection
RRT leader,
$45/hour
1 hour/month $540 Hospitalist VP Medical
Affairs
Data entry Administrative
assistant,
$15/hour
1 hour/month $180 Nursing
administration
Medical–

surgical
director
Data
analysis
Data manager,
$21/hour
1 hour/month $252 Quality Quality
manager
First Year Start-Up Costs
Education
prep
Advanced practice
nurse, $45/hour
2 Project leaders,
$30/hour
Nurse manager,
$40/hour
6 hours
6 hours each
2 hours
$270
$360

$80
Total = $710
3 North Nursing 3 North Nurse
manager
Unit educators
will schedule their
time to provide
the in-services.
No additional
cost.
Education
delivery
80 Staff members,
$30/hour (average
rate)
1/2 hour each $1,200 Departmental
education
budgets
Department
managers
This is the cost for
the pilot unit only.
http://links.lww.com/AJN/A19

the project (see Table 2 at http://
links.lww.com/AJN/A21). The
team further discusses how it can
maintain the project’s momen-
tum by keeping it moving for-
ward while at the same time
accommodate unexpected delays
or resistance. There are a few
items on the timeline that Carlos
thinks may be underestimated―
for example, the team may need
more than a month to meet with
other departments because of al-
ready heavily scheduled calendars―
but he decides to let it stand as
drafted, knowing that it’s a guide
and can be adjusted as the need
arises.
Budget. Carlos discusses the
budget with the team. Rebecca
shares a list of what she thinks
they’ll need for the project and the
team decides to put this informa-
tion into a table format so they can
more easily identify any missing
information. Before they construct
the table, they walk through an
imaginary RRT call to be sure
they’ve thought of all the budget
implications of the project. They
realize they didn’t include the cost
of each employee attending an

education session, so they add
that figure to the budget. They
also realize that they’re missing
hourly pay rates for the different
types of employees involved. Car-
los tells Rebecca that he’ll work
with the Human Resources De-
partment to obtain this informa-
tion before the meeting so they
can complete the budget (see
Table 3).
REVIEWING THEIR WORK
The next time they meet, the EBP
team reviews the agenda for the
meeting and the documents they’ll
be presenting. The clerical person
on Rebecca and Chen’s floor (some-
times called the unit secretary)
has kept a record of who’s attend-
ing the meeting and the team is
pleased that most of the stake-
holders are coming. Carlos in-
forms the team that he received
notification that their internal re-
view board submission has been
approved. They’re excited to check
that step off on their EBP Imple-
mentation Plan.
Carlos suggests that they dis-
cuss the kick-off meeting in detail
and brainstorm how to prepare
for any negative responses to their
project that might occur. Rebecca

and Chen remark that they’ve
never considered that someone
might not like the idea of an RRT.
Carlos says he’s not surprised; of-
ten the passion that builds around
an EBP project and the hard work
put into it precludes taking time
to think about “why not.” The
team talks about the importance
of stopping occasionally during
any project to assess the environ-
ment and par ticipants, recogniz-
ing that people often have different
perspectives and that everyone
may not support a change. Carlos
reminds the team that people
may simply resist changing the
routine, and that this can lead to
the sabotage of a new idea. As
they explore this possible resis-
tance, Rebecca shares her concern
that with everyone in the hospital
so busy, adding something new
may be too stressful for some peo-
ple. Carlos tells Rebecca and Chen
that helping project participants
realize they’ll be doing the same
thing they’ve been doing, just in a
more efficient and effective way, is
generally successful in helping them
accept a new process. He reminds
them that many of the people on
the RRT are the same people who
currently take care of patients if

they code or are admitted to the
ICU; however, with the RRT pro-
tocol, they’ll be intervening ear-
lier to improve patients’ outcomes.
The team feels confident that, if
needed, they can use this approach
at the kick-off meeting.
CONDUCTING THE KICK-OFF MEETING
Rebecca and Chen are both ner-
vous and excited about the meet-
ing. Carlos has made sure they’re
well prepared by helping them set
up the meeting room, computer,
PowerPoint presentation, and
handout packets containing the
agenda and draft documents. The
team is ready, and they’ve placed
themselves at the head of the ta -
ble so they can be visible and ac-
cessible. As the invitees arrive,
they welcome each one individu-
ally, thanking them for participat-
ing in this important meeting.
The team makes sure that the
meeting is guided by the agenda
and moves along through the
presentation of information to
thoughtful questions and a lively
discussion.
Join the EBP team next time as
they launch the RRT project and
tackle the real-world issues of
project implementation. ▼

Lynn Gallagher-Ford is assistant direc -
tor of the Center for the Advancement
of Evidence-Based Practice at Arizona
State University in Phoenix, where Ellen
Fineout-Overholt is clinical pro fessor and
director, Susan B. Stillwell is associate di -
rector, and Bernadette Mazurek Melnyk
is dean and distinguished foundation pro -
fessor of nursing at the College of Nursing
and Health Innovation. Contact author:
Lynn Gallagher-Ford, lynn.gallagher-[email protected]
asu.edu.
REFERENCE
1. Choo CL, et al. Rapid response team:
a proactive strategy in man aging …
Original Article
A Test of the ARCC C© Model Improves
Implementation of Evidence-Based Practice,
Healthcare Culture, and Patient Outcomes
Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FAANP,
FNAP, FAAN •
Ellen Fineout-Overholt, RN, PhD, FNAP, FAAN • Martha
Giggleman, RN, DNP,
NEA-BC • Katie Choy, RN, DNP, CNS, NEA-BC
Keywords
ARCC,
evidence-based

practice,
organizational
culture,
patient outcomes
ABSTRACT
Background: Although several models of evidence-based
practice (EBP) exist, there is a paucity
of studies that have been conducted to evaluate their
implementation in healthcare settings.
Aim: The purpose of this study was to examine the impact of
the Advancing Research and
Clinical practice through close Collaboration (ARCC) Model on
organizational culture, clinicians’
EBP beliefs and EBP implementation, and patient outcomes at
one healthcare system in the
western United States.
Design: A pre-test, post-test longitudinal pre-experimental
study was conducted with follow-up
immediately following full implementation of the ARCC Model.
Setting and Sample: The study was conducted at a 341-bed
acute care hospital in the western
region of the United States. The sample consisted of 58
interprofessional healthcare professionals.
Methods: The ARCC Model was implemented in a sequential
format over 12 months with the
key strategy of preparing a critical mass of EBP mentors for the
healthcare system. Healthcare
professionals’ EBP beliefs, EBP implementation, and
organizational culture were measured with
valid and reliable instruments. Patient outcomes were collected

in aggregate from the hospital’s
medical records.
Results: Findings indicated significant increases in clinicians’
EBP beliefs and EBP implementation
along with positive movement toward an organizational EBP
culture. Study findings also indicated
substantial improvements in several patient outcomes.
Linking Evidence to Action: Implementation of the ARCC
Model in healthcare systems can en-
hance clinicians’ beliefs and implementation of evidence-based
care, improve patient outcomes,
and move organizational culture toward EBP.
INTRODUCTION AND BACKGROUND
It is well known that evidence-based practice (EBP) improves
healthcare quality, safety, and patient outcomes as well as fos-
ters clinicians’ active engagement in their practices. Nurses
who use an evidence-based approach to care and practice in
cultures that support EBP are more empowered as they are
able to make a difference in the care of their patients. Although
the positive impact of EBP has been demonstrated through
multiple studies, major barriers exist that prevent EBP from
becoming the standard of care throughout the world. These
barriers include (a) inadequate EBP knowledge and skills of
clinicians, (b) misperceptions that EBP takes too much time,
(c) organizational culture and politics, (d) lack of support from
nurse leaders and managers, and (e) inadequate resources and
investment in EBP (Jun, Kovner, & Stimpfel, 2016; Melnyk
et al., 2016; Melnyk, Fineout-Overholt, Gallagher-Ford, & Ka-
plan, 2012). Aside from equipping clinicians with the knowl-
edge and skills needed to attain the EBP competencies and con-
sistently implement evidence-based care, findings from studies
have indicated that clinician access to EBP mentors can play a

key role in their implementation of EBP and the development
of organizational cultures that support the delivery of evidence-
based care (Fineout-Overholt & Melnyk, 2015; Melnyk, 2007).
Although several EBP models exist, most are process mod-
els that outline the steps of EBP or the sequence of conducting
an EBP project. EBP process models include the Johns Hopkins
Nursing Evidence-Based Practice Model (Dearholt & Dang,
2012), the Iowa Model of Evidence-Based Practice to Promote
Quality Care (Titler et al., 2001), the Model for Evidence-Based
Practice Change (Rosswurm & Larabee, 1999), and the ACE
Star Model of Knowledge Transformation (Stevens, 2012).
Unlike EBP process models, the Advancing Research and
Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9. 5
C© 2016 Sigma Theta Tau International
A Test of the ARCC C© Model Improves Implementation of
Figure 1. The Advancing Research and Clinical Practice
Through Close Collaboration (ARCC) Model.
Clinical practice through close Collaboration (ARCC) Model is
a system-wide model to advance and sustain EBP in healthcare
systems (see Figure 1). The first step in implementing the
ARCC Model is an organizational assessment of the current
EBP culture in order to identify strengths and major barriers
to EBP in the healthcare system so that strategies can be
implemented to remove those barriers. At the core of the
ARCC Model is a critical mass of EBP mentors who, through
intentional strategic initiatives, assist point of care clinicians
in enhancing their beliefs about the value of EBP and their
confidence in implementing it. As a result, ARCC contends

that heightened EBP beliefs in clinicians result in greater
implementation of evidence-based care, which ultimately
leads to higher job satisfaction, less staff turnover, and
improved patient outcomes. Several studies now support the
relationships among key constructs in the ARCC Model (Levin,
Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011; Melnyk,
2012; Melnyk & Fineout-Overholt, 2002; Melnyk et al., 2004;
Melnyk, Fineout-Overholt, & Mays, 2008; Melnyk, Fineout-
Overholt, Giggleman, & Cruz, 2010; Wallen et al., 2010).
AIM
The purpose of this study was to examine the impact of the
ARCC Model on organizational culture, clinicians’ EBP beliefs
and EBP implementation, and patient outcomes at one health-
care system in the western region of the United States.
DESIGN
A pre-test, post-test longitudinal pre-experimental study was
conducted with follow-up immediately following full imple-
mentation of the ARCC Model. Institutional Review Board ap-
proval was obtained from the authors’ institution as well as the
organization’s research subject review board.
SETTING AND SAMPLE
This study was conducted at Washington Hospital Healthcare
System, a 341-bed acute care hospital in the San Francisco
bay area. The sample consisted of 58 interprofessional health-
care professionals, with complete follow-up data for 45 partic-
ipants. Participants were point of care nurses, administrators,
nurse managers, clinical nurse specialists, respiratory thera-
pists, occupational therapists, physical therapists, dieticians,
social workers, and pharmacists. Although physician cham-
pions participated in the projects, they were not part of the
data collection. Only the project teams participated in data
collection.

METHODS
The ARCC Model was implemented in a sequential format
over 12 months with the key strategy of preparing a critical
mass of EBP mentors for the healthcare system. Intensive EBP
workshops were first provided to the 58 participants in order
to enhance their knowledge and skills in the seven steps of
6 Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9.
Original Article
Table 1. Examples of PICOT Questions Formulated
by the EBP Teams
� In ventilated intensive care unit patients (P), howdoes early
ambulation (I) compared to routinely scheduledambulation
(C) affect length of stay andepisodesof ventilator
associatedpneumoniawhile in the intensive care unit (T)
� In congestive heart failure patients (P), howdoes
comprehensive pre-discharge education (I) compared to
standardpre-discharge education (C), affect readmission
rates to thehospital (O)?
EBP. In addition, content and skills building in the workshops
focused on how to facilitate individual behavior change of clin-
icians to implement EBP and how to facilitate an EBP organi-
zational culture. The 58 participants were divided into working
teams of six to eight members who were to collaborate on
an EBP change project to improve patient outcomes within
the hospital. Each team was then charged with formulating
a PICOT (Patient population, Intervention or Issue of inter-
est, Comparison intervention or issue, Outcome, and Time for
the intervention to achieve the outcome if relevant) question

about an important clinical issue, systematically searching for
the best evidence, and critically appraising and synthesizing
the evidence culminating in a recommendation for practice.
See Table 1 for examples of PICOT questions developed by
the teams. Strategic plans were then developed by the inter-
professional EBP mentor teams to implement and evaluate the
impact of the EBP changes on clinical outcomes within their
organization. After implementation and evaluation of the prac-
tice changes were completed, the final step for the teams was
to submit their projects for presentation at local, regional, or
national conferences to disseminate their successes to others
within the healthcare community.
OUTCOMES
Study variables were measured with the following valid and
reli-
able instruments. The Evidence-Based Practice Beliefs (EBPB)
Scale Melnyk & Fineout-Overholt, 2003a) measured clinicians’
beliefs about EBP and their ability to implement it. The 16-item
Likert scale has established face, content, and construct valid-
ity with internal consistency reliabilities greater than .85 across
multiple studies (Melnyk et al., 2008). Responses on the scale
range from 1 (strongly disagree) to 5 (strongly agree). Examples
of items on the scale include (a) I am clear about the steps in
EBP, (b) I am sure that I can implement EBP, and (c) I am sure
that evidence-based guidelines can improve care.
The Evidence-Based Practice Implementation (EBPI) Scale
measured delivery of evidence-based care (Melnyk & Fineout-
Overholt, 2003b). Participants respond to each of the 18 Likert
scale items on the EBPI by answering how often in the last
eight weeks they have performed certain EBP activities, such as
(a) generated a PICOT question about my practice, (b) used evi-
dence to change my clinical practice, (c) evaluated the
outcomes

of a practice change, and (d) shared the outcome data collected
with colleagues. The EBPI has established face, content, and
construct validity as well as internal consistency reliabilities
greater than .85 across multiple studies (Melnyk et al., 2008).
The Organizational Culture and Readiness Scale for
System-Wide Integration of Evidence-Based Practice (OCR-
SIEP) measured the organization’s culture and its readiness
for system-wide EBP (Fineout-Overholt & Melnyk, 2006). This
instrument contains 26 Likert scale items that identify a de-
scription of the existing support in the current culture for EBP,
which offers insight into the strengths and opportunities for
fostering evidence-based care within a healthcare system. The
OCRSIEP scale has established face and content validity along
with excellent internal consistency reliability of greater than .85
across multiple samples (Melnyk & Fineout-Overholt, 2015).
Examples of items on the OCRSIEP include the following:
(a) To what extent is EBP clearly described as central to the
mission and philosophy of your institution? (b) To what extent
do you believe that EBP is practiced in your organization? And
(c) To what extent is the nursing staff with whom you work
committed to EBP?
Patient Outcomes
Aggregate data were gathered by the teams, including data
from the hospital’s medical records (e.g., number of cases of
ventilator associated pneumonia, hospital readmission rates)
before and after implementation of the ARCC Model to evaluate
relevant patient outcomes as results of the EBP projects.
Analyses
T tests and effect sizes were calculated for study variables to
evaluate pre-to-post differences. A p value of .05 was set for
statistical significance.
RESULTS

Findings indicated that the clinicians’ EBP beliefs, EBP im-
plementation, and movement of organizational culture toward
EBP significantly increased over the 12-month project. Specif-
ically, clinicians’ EBP beliefs (n = 45) increased significantly
from baseline (M = 60.7, SD = 7.6) to follow-up (M = 64.9,
SD = 6.7; t = 4.2; p = .00; effect size = .62, which is a medium
to large positive effect for ARCC). EBP implementation also
significantly increased from baseline (M = 17.8, SD = 10.3) to
follow-up (M = 51.9, SD = 16.8; t = 12.9; p = .00; effect size =
2.3, indicating a large positive effect for ARCC). In addition,
organizational culture and readiness for EBP increased signifi-
cantly from baseline (M = 80.9; SD = 90.8) to follow-up (M =
90.8; SD = 14.7; t = 3.9; p = .00; effect size = .70, which
is a medium to large positive effect for ARCC). In addition,
as a result of implementing the ARCC Model, evidence-based
interventions improved key patient outcomes (see Table 2).
A Test of the ARCC C© Model Improves Implementation of
Table 2. Project Outcomes From Implementation
of the EBP Changes
� Apractice change to early ambulation in the ICU led to a2.7
reduction in ventilator days (11.6–8.9) andno ventilator
associatedpneumonia.
� With the implementation of apressure ulcer prevention
nursing standardizedprocedure onamedical-surgical unit,
the acquiredpressure ulcer ratewas significantly decreased
from6.07%to0.62%1year later.

� Comprehensive educationof congestive heart failure
patients led to a 14.7%reduction in hospital readmissions.
� After implementation of family centered care on the
pediatric unit, 75%of parents perceived theoverall quality
of care as excellent compared to22%pre-implementation.
� Thepercentageofmothers not supplementing their breast
milkwith formula increased from61.7% to71.1%after the
evidence-basedbaby friendly hospital initiativewas
implemented.
� After implementation of a nurse-initiatedpain protocol in
the emergency room(ER),wait time for painmedication
decreased from46minutes to 13minutes and length of stay
in theERalsodecreased from120minutes to91minutes.
DISCUSSION
Findings support the positive impact of implementing the
ARCC Model on clinicians’ EBP beliefs and a dramatic in-
crease in EBP implementation in those who participated in the
project. Organizational culture at the hospital shifted greatly
toward system-wide EBP. Most important, as a result of imple-
menting ARCC, there were multiple improvements in patient
outcomes.
The establishment of a cadre of EBP mentors is cen-
tral to building an organizational culture of EBP and im-
plementing evidence-based care. The EBP mentors in this
study garnered the knowledge and skills needed to successfully
implement and evaluate EBP changes within the hospital as
well as to work with their colleagues in creating an EBP culture
in which to deliver high-quality evidence-based care. These
findings affirm that culture eats strategy and assists clini-
cians in making EBP the social norm within a system (Mel-

nyk, 2016b). Without a culture and environment that supports
EBP, high-quality evidence-based care will not sustain (Melnyk,
2016a).
Numerous healthcare systems and hospitals throughout the
United States and globe have implemented the ARCC Model in
their efforts to build and sustain an EBP culture and environ-
ment in their organizations. As a part of building this culture,
position descriptions have been created or changed to include
responsibilities as an EBP mentor. For example, at The Ohio
State University Wexner Medical Center, the primary responsi-
bility of the clinical nurse specialists throughout the healthcare
system is to serve as EBP mentors for point of care staff in
improving patient outcomes. Part of this role is ensuring
compliance with the EBP competencies for advanced practice
nurses (Melnyk, Gallagher-Ford, & Fineout-Overholt, 2016;
Melnyk, Gallagher-Ford, Long & Fineout-Overholt, 2015).
Research is needed to further confirm the advantages of
using particular EBP models in real-world practice settings,
including how implementation of these models impact both
clinician, leader and patient outcomes (Dang et al., 2015). Com-
parative effectiveness studies that evaluate the benefits of in-
dividual models as well as combining models also are needed.
Those hospitals and systems who use an EBP model to guide
implementation of evidence-based care should document their
experiences and outcomes in order to better understand the
model’s usefulness in facilitating EBP and share this impor-
tant information with others who might use the model (Gra-
ham, Tetroe, & KT Theories Research Group, 2007). Return
on investment by including cost outcomes also should be eval-
uated. WVN
LINKING EVIDENCE TO ACTION

� The ARCC Model is an evidence-based system-
wide model for advancing the implementation and
sustainability of EBP.
� A key strategy in the ARCC model is the develop-
ment of a critical mass of EBP mentors who assist
point of care clinicians in the consistent imple-
mentation of evidence-based care.
� Use of ARCC EBP mentors enhances the EBP be-
liefs and EBP implementation of clinicians and
strengthens the EBP culture of an organization.
� An organizational culture of EBP is central to sup-
porting sustainable high quality evidence-based
care.
� Implementation of the ARCC Model can substan-
tially improve patient outcomes.
Author information
Bernadette Mazurek Melnyk, Associate Vice President for
Health Promotion, University Chief Wellness Officer, Dean
and Professor, College of Nursing, Professor of Pediatrics &
Psychiatry, and College of Medicine, The Ohio State Univer-
sity, Columbus, Ohio; Ellen Fineout-Overholt, Mary Coulter
Dowdy Distinguished Professor of Nursing, College of Nurs-
ing & Health Sciences University of Texas at Tyler, Tyler,
Texas;
Martha Giggleman, Healthcare Consultant & Advocate Liver-
more, California; Katie Choy, Senior Director, Nursing Practice
and Education, Washington Hospital Healthcare System, Fre-
mont, California
8 Worldviews on Evidence-Based Nursing, 2017; 14:1, 5–9.

Original Article
Address correspondence to Dr. Bernadette Mazurek Melnyk,
The Ohio State University, 145 Newton Hall, 1585 Neil Avenue,
Columbus, OH 43210; [email protected]
Accepted 16 September 2016
Copyright C© 2017, Sigma Theta Tau International
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Nursing Clinics of North America, 13(4), 497–509.
Wallen, G. R., Mitchell, S. A., Melnyk, B. M., Fineout-
Overholt, E.,
Miller-Davis, C., Yates, J., & Hastings, C. (2010). Implement-
ing evidence-based practice: Effectiveness of a structured mul-
tifaceted mentorship programme. Journal of Advanced Nursing,
66(12), 2761–2771.
doi 10.1111/wvn.12188
WVN 2017;14:5–9
Copyright of Worldviews on Evidence-Based Nursing is the

property of Wiley-Blackwell and
its content may not be copied or emailed to multiple sites or
posted to a listserv without the
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may print, download, or email
articles for individual use.
LWW/NAQ NAQ200184 March 1, 2012 23:19
Nurs Admin Q
Vol. 36, No. 2, pp. 127–135
Copyright c© 2012 Wolters Kluwer Health | Lippincott
Williams & Wilkins
Achieving a High-Reliability
Organization Through
Implementation of the ARCC
Model for Systemwide
Sustainability of
Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP,
FNAP, FAAN
High-reliability health care organizations are those that provide
care that is safe and one that min-
imizes errors while achieving exceptional performance in
quality and safety. This article presents
major concepts and characteristics of a patient safety culture
and a high-reliability health care
organization and explains how building a culture of evidence-
based practice can assist organiza-
tions in achieving high reliability. The ARCC (Advancing

Research and Clinical practice through
close Collaboration) model for systemwide implementation and
sustainability of evidence-based
practice is highlighted as a key strategy in achieving high
reliability in health care organizations.
Key words: evidence-based practice, high-reliability
organizations, patient safety
H IGH-RELIABILITY ORGANIZATIONS(HROs) are those that
achieve a high
degree of safety or reliability despite dan-
gerous or hazardous conditions.1 They have
defect-free or error-free operations for long
periods of time.2 The Blue Angels and the
aviation industry are excellent examples of
HROs. The Blue Angels are the United States
Navy’s Flight Demonstration Squadron and
the oldest formal flying aerobatic team. They
operate 6 F/A-18 Hornet aircraft and conduct
more than 70 daring flight exhibits every year
throughout the United States in which they
Author Affiliation: College of Nursing, The Ohio
State University, Columbus.
The author declares no conflict of interest.
Correspondence: Bernadette Mazurek Melnyk, PhD,
RN, CPNP/PMHNP, FNAP, FAAN, College of Nursing, The
Ohio State University, 1585 Neil Ave, Columbus, OH
43210 ([email protected]).
DOI: 10.1097/NAQ.0b013e318249fb6a
perform many extremely dangerous maneu-
vers, including high-speed passes (often just

under the speed of sound), slow passes, fast
rolls, tight turns, and the Diamond formation.
Training and performance require intense
focus, strong leadership, effective commu-
nication, teamwork, data-based practices,
root-cause analysis of errors, a safety and
continuous learning culture, improvement
processes, and an outcomes evaluation.
The health care industry, which has been
fraught with an epidemic of medical errors,
has looked to HROs to learn about and imple-
ment cultures along with practices that will
lead to safer environments with a higher qual-
ity of care and efficiency. Every year, there
are up to 200,000 unintended patient deaths,
more than the number of deaths that occur
due to motor vehicle accidents, breast can-
cer, and AIDS.3 Patient injuries happen to ap-
proximately 15 million individuals per year.
Only 5% of medical errors are caused by
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized
127
LWW/NAQ NAQ200184 March 1, 2012 23:19
128 NURSING ADMINISTRATION QUARTERLY/APRIL–
JUNE 2012
incompetence, whereas 95% of errors in-
volve competent clinicians trying to attain

the best outcomes in poorly designed sys-
tems with poor uniformity.4 Furthermore,
core processes in health care are defective
50% of the time and patients receive only ap-
proximately 55% of the care that they should
when entering the health care system.5
The movement to improve patient safety in
health care systems accelerated after the land-
mark publication by the Institute of Medicine
of To Err Is Human: Building a Safer Health
System.6 Evidence regarding major factors
that reduce errors in health care systems in-
clude (a) effective communication and trans-
disciplinary teamwork; (b) evidence-based
interventions, which also improve standard-
ization of care and decrease variation; (c)
sensitivity to operations; and (d) improved
systems design, which includes the use of
checklists, decreasing interruptions, prevent-
ing fatigue, avoiding task saturation, reducing
clinician stress, and improving environmen-
tal conditions.1,7,8 In addition to the current
emphasis on reducing medical errors, pay for
performance has placed pressure on health
care systems to improve their quality of care
and prevent sentinel events.
One key strategy to improving quality
of care is through the implementation of
evidence-based practice (EBP). However, de-
spite an aggressive research movement, the
majority of findings from research are often
not translated into clinical practice to enhance
care and patient outcomes. At best, it usu-
ally takes several years to translate research

findings into health care settings to improve
patent care. In an era of cost-driven health
care systems, research that demonstrates a re-
duction in costs has a higher probability of be-
ing adopted in clinical practice. For example,
through a series of 6 randomized controlled
trials, the efficacy of the COPE (Creating Op-
portunities for Parent Empowerment) pro-
gram has been established with parents of hos-
pitalized/critically ill children and premature
infants. Findings from these trials have indi-
cated that when parents receive COPE versus
an attention control program, parents report
less stress, anxiety, depression, and posttrau-
matic stress symptoms, up to 2 years follow-
ing hospitalization.9-14 In addition, their chil-
dren have better developmental and behavior
outcomes. However, it was not until a clini-
cal trial using COPE with parents of preterms
demonstrated a 4-day shorter length of neona-
tal intensive care unit (ICU) stay (8 days
shorter for preterms younger than 32 weeks)
that hospitals and insurers began implement-
ing the program.10 Routine implementation
of the COPE program to the parents of the
more than 500 000 preterm infants born in the
United States every year could save the health
care system between $2.5 billion and $5 bil-
lion per year.15 This is an example of the “so
what factor” in an era of health care reform,
which is conducting research and EBP/quality
improvement projects with high-impact po-
tential to positively change health care sys-
tems, reduce costs, and improve outcomes
for patients and their families.16 Key questions

that anyone should ask themselves when em-
barking on a research study or EBP/quality
improvement project should be as follows:
(1) So what will the outcome of the study
or project be once it is completed? and (2)
So what difference will the study or project
make in improving health care quality, costs,
or patient outcomes?
Estimates are that the cost of health care de-
livery in the United States is $2.3 trillion a year,
a tripling of its cost in the past 2 decades.17
Poor quality health care cost the United States
approximately $720 billion in 2008. Wasteful
health care spending costs the health care sys-
tem $1.2 trillion annually. Half of American
hospitals are functioning in deficit.18 In addi-
tion to EBP improving patient outcomes by at
least 28%, the US health care system could re-
duce health care spending by 30% if patients
receive evidence-based care.19
HIGH-RELIABILITY HEALTH CARE
ORGANIZATIONS
A high-reliability health care organization
(HRHO) provides care that is safe and one that
minimizes errors while achieving exceptional
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized
LWW/NAQ NAQ200184 March 1, 2012 23:19

The ARCC Model for Systemwide Sustainability of EBP 129
performance in quality and safety. It has a mea-
surable, near perfect performance on quality
of care, patient safety, and efficiency. Creat-
ing a culture and processes that radically re-
duce system failures and effectively respond-
ing when failures do occur is the goal of HROs.
FIVE KEY CONCEPTS OF
HIGH-RELIABILITY HEALTH
CARE ORGANIZATIONS
The first key concept of an HRHO is sensi-
tivity to operations, which is an awareness of
the state of systems and processes that affect
patient care. When an organization is sensi-
tive to operations, potential errors are identi-
fied and prevented. In addition, actual errors
are identified immediately and corrected.20
The second key concept of HRHO is a reluc-
tance to simplify. It is positive to create simple
processes in health care systems but not to
oversimplify explanations for adverse events.
For example, if a clinician makes a medical
error, it would be simple to conclude that the
clinician was the cause of the error instead
of investigating the complete chain of events,
from the physician’s order to the filling of that
order by a pharmacist to the delivery of the
medication.
The third key concept in an HRHO is pre-
occupation with failure. Although it is very

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