TTHIS IS LECTURER COMMENT FOR MODULE 5 ASSIGNMENT.Slide 2 The.docx

TTHIS IS LECTURER COMMENT FOR MODULE 5
ASSIGNMENT.
Slide 2: There is a typo in the notes page. The info on the slide
is repeated in the notes page.
Slide 3: There are grammatical errors.
Slide 8: The article title in the reference list should be
formatted like a sentence, only the first word should start with a
capital letter. See Section 6.29 on page 185 of the APA manual.
Describe the current problem or opportunity for change. The
problem is not identified. What is the current problem? Include
in this description the circumstances surrounding the need for
change, the scope of the issue, the stakeholders involved, and
the risks associated with change implementation in general.
Who are the stakeholders and what are the risks?
Identify an evidence-based idea for a change in practice.
What is your plan for knowledge transfer of this change,
dissemination, and organizational adoption and implementation?
This is not included in the slides.
· Describe the measurable outcomes you hope to achieve with
the implementation of this evidence-based change. I do not see
outcomes identified.
The tables are not mentioned. Each study is summarized in one
or two slides. There is no synthesis of the knowledge to
determine interventions to implement.
Some of the information from the tables is copied onto the
slides, but there is no clearly identified knowledge gained from
each table. Talk about the studies as a whole. Look at all the
outcomes across the table-what do you know about all the
studies? Look at all of the results across the table-what do you
know? What level of evidence were the studies? All level1?
Based on the tables what can be implemented?
There is a title slide and two slides with introduction. After that
there are about 1-2 slides per study, making a summary. No

conclusions are drawn. No discussion of dissemination. There
is no reference list.
It's harder to put bubbles on the slides so most comments are
here. Let me know if there are questions.
Describe the current problem or opportunity for change. The
problem is not identified. What is the current problem? Include
in this description the circumstances surrounding the need for
change, the scope of the issue, the stakeholders involved, and
the risks associated with change implementation in general.
Who are the stakeholders and what are the risks? Identify an
evidence-based idea for a change in practice. What is your plan
for knowledge transfer of this change, dissemination, and
organizational adoption and implementation? This is not
included in the slides. · Describe the measurable outcomes you
hope to achieve with the implementation of this evidence-based
change. I do not see outcomes identified. The tables are not
mentioned. Each study is summarized in one or two slides.
There is no synthesis of the knowledge to determine
interventions to implement. Some of the information from the
tables is copied onto the slides, but there is no clearly identified
knowledge gained from each table. Talk about the studies as a
whole. Look at all the outcomes across the table-what do you
know about all the studies? Look at all of the results across the
table-what do you know? What level of evidence were the
studies? All level1? Based on the tables what can be
implemented?
High Speed Response Teams for Patients.
Name
Institutional Affiliation
Date

High speed response teams for patients is also known as the
medical emergency team (MET).
is also known as the high acuity response team (HART).
It is a team of healthcare providers responsible for responding
to the hospitalized clients.
The targeted patients using this kind of response are those with
early signs of deterioration.
Introduction
High speed response teams for patients is also known as the
medical emergency team (MET). It is also refered to as the high
acuity response team (HART). This is a team of healthcare
providers who are responsible for responding to the hospitalized
clients. The targeted patients using this kind of response are
those with early signs of deterioration.
2
The patients are on non-intensive care units.
The response it used to assists in the prevention of respiratory
or cardiac arrest.
This paper therefore aims at discussing the information
provided by four articles on the topic related to high speed
response Team for Patients

Cont’d
These patients are on non-intensive care units. It is used to help
in the prevention of respiratory or cardiac arrest. This paper
therefore aims at discussing the information provided by four
articles on the topic related to high speed response Team for
Patients
3
Objective: to assess the impacts of delayed response by the
rapid response team.
The impact being assessed was related to the number of reported
deaths, cardiac arrest, and the rates of intensive care transfer.
Methods used: the review involved both randomized and non-
randomized research works.
Xu, M. K., Dobson, K. G., Thabane, L., & Fox-Robichaud, A.
(2018). Evaluating the effect of delayed activation of rapid
response teams on patient outcomes: a systematic review
protocol. Systematic Reviews, 7 (1), 42.
The main objective of the authors of this article was to assess
the impacts of delayed response by the rapid response team. The
impact being assessed was related to the number of reported
deaths, cardiac arrest, and the rates of intensive care transfer.
According to his article a review involving both randomized and
non-randomized research works was adopted.
4

Rapid response team have been widely adopted in the global
healthcare sector.
They are helping in the detection and reaction to the
deterioration of the patient population.
Lack of evidence regarding their effectiveness is brought by the
absent of standardized strategy regarding their use and
implementation.
Cont’d
Authors states that rapid response team have been widely
adopted in the entire world within the healthcare sector. Rapid
response Team are helping in the detection and reaction to the
deterioration of the patient population. There is lack of
evidence regarding their effectiveness due to absent of
standardized strategy regarding their use and implementation.
5
Objective: to assess whether the intervention which involves
crew resource management training of the team leaders helps in
the improvement of performance.
Method: in situ observation of the Rapid Response Team
activation.
The dynamic of the performance from the team were measured
through observation adherence to the ideal task and use of the
Team Emergency Assessment Measure Tool.
Siems, A., Cartron, A., Watson, A., McCarter, R., & Levin, A.
(2017). Improving pediatric rapid response team performance
through crew resource management training of team leaders.
Hospital pediatrics, 7 (2), 88-95.

The study was aimed at assessing whether the intervention
which involves crew resource management training of the team
leaders helps in the improvement of performance. The method
used by the authors were the in situ observation of the Rapid
Response Team activation. The dynamic of the performance
from the team were measured through observation adherence to
the ideal task and use of the Team Emergency Assessment
Measure Tool.
6
Response Team are helping in the improvement of the means of
detection and responses to the deteriorating patients.
The outcome of this study shows that the use of the targeted
crew resources management of the team leaders is crucial
It helps in increasing the team performance as well as the
dynamics of the patients who needs transfer to the intensive
care units.
The trained team leaders helps in the improvement of the
behaviors of the Rapid Response team members who are not
trained.
Cont’d
According to this study, Rapid Response Team are helping in
the improvement of the means of detection and responses to the
deteriorating patients. The outcome of this study shows the use
of the targeted crew resources management of the team leaders

is helping in increasing in the team performance as well as the
dynamics of the patients who needs transfer to the intensive
care units. The trained team leaders helps in the improvement of
the behaviors of the Rapid Response team members who are not
trained.
7
Obective: to quantitatively give a description of the effects of
the High Speed Response Team at 944 bed within the university
affiliated healthcare facility.
Method: open-ended interviews using 49 questions were used
Positive outcomes: improvement in the morale of nurses and the
real time distribution of the workload for nurses.
Negative impacts: increased tensions between nurses and
physicians, burden to the response team, and reduction in the
autonomy of the trainees.
High speed response team offer benefits related to the reduction
in the rates of transfers to the ICU.
Benin, A. L., Borgstrom, C. P., Jeng, G. Y., Roumanis, S. A., &
Horwitz, L. I. (2012). Defining Impact of a Rapid Response
Team: Qualitative Study with Nurses, Physicians, and Hospital
Administrators. Postgraduate Medical Journal, 88 (1044), 575-
582.
Authors of this study aimed at quantitatively give a description
of the effects of the High Speed Response Team at 944 bed
within the unversity affiliated healthcare facility. Open-ended
interviews using 49 questions were used for the administrators,
physicians, trainees, and the Rapid Response Team specialists,
nurses, and the respiratory technicians. The outcomes of the

study revealed a positive related to the improvement in the
morale of nurses and the real time distribution of the workload
for nurses. The negative impacts included increased tensions
between nurses and physicians, burden to the response team,
and reduction in the autonomy of the trainees. It was clear that
high speed response team offer benefits related to the reduction
in the rates of transfers to the ICU.
8
Objective: to determine the prolonged impact of the rapid
response team implementation on the failure to rescue.
Method: longitudinal research work on the performance of the
institution through using control charts and Bayesian Charge
Point (BCP) assessment.
Setting: academic healthcare facility in the Midwest, USA.
Moriarty, J. P., Schiebel, N. E., Johnson, M. G., Jensen, J. B.,
Caples, S. M., Morlan, B. W., et al. (2014). Evaluating
implementation of a rapid response team: considering
alternative outcome measures. International Journal for Quality
in Health Care, 26 (1), 49-57.
Authors of this article aimed at determining the prolonged
impact of the rapid response team implementation on the failure
to rescue. Authors of this study employed longitudinal research
work on the performance of the institution through using control
charts and Bayesian Charge Point (BCP) assessment. The study
was performed at academic healthcare facility in the Midwest,
USA.
9

There was a reduction in the failure to rescue.
There was an increase in the unanticipated rate of the intensive
care unit transfers.
There was a greater reduction in the mortality amongst non-
intensive care unit discharges in the control charts.
Cont
The outcome of the study reveal about a reduction in the failure
to rescue. There was an increase in the unanticipated rate of the
intensive care unit transfers. There was a greater reduction in
the mortality amongst non-intensive care unit discharges in the
control charts.
10
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
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
Evidence-Based Practice
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), how does early
ambulation (I) compared to routinely scheduled ambulation
(C) affect length of stay and episodes of ventilator
associated pneumonia while in the intensive care unit (T)
� In congestive heart failure patients (P), how does
comprehensive pre-discharge education (I) compared to
standard pre-discharge education (C), affect readmission

rates to the hospital (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
� A practice change to early ambulation in the ICU led to a 2.7
reduction in ventilator days (11.6–8.9) and no ventilator
associated pneumonia.
� With the implementation of a pressure ulcer prevention
nursing standardized procedure on a medical-surgical unit,
the acquired pressure ulcer rate was significantly decreased
from 6.07% to 0.62% 1 year later.
� Comprehensive education of 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 the overall quality
of care as excellent compared to 22% pre-implementation.
� The percentage of mothers not supplementing their breast
milk with formula increased from 61.7% to 71.1% after the
evidence-based baby friendly hospital initiative was
implemented.
� After implementation of a nurse-initiated pain protocol in
the emergency room (ER), wait time for pain medication
decreased from 46 minutes to 13 minutes and length of stay
in the ER also decreased from 120 minutes to 91 minutes.
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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doi 10.1111/wvn.12188
WVN 2017;14:5–9
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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

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
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
reproduction of this article is prohibited.
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
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
important to gather meticulous data on the
number of medical errors or sentinel events
in a health care system, when an error or ad-
verse event happens, it is an opportunity to
thoroughly examine the root cause for the
problem and to make improvements.
The fourth key concept in an HRHO is def-
erence to expertise. In an HRHO, leaders lis-
ten to and respond to others’ insights, includ-
ing direct care clinicians, patients, and family
members. Input from others is taken into con-
sideration in establishing care processes and
strategies to improve safety and quality.

The fifth key concept in an HRHO is re-
silience. In an HRHO, leaders and staff need
to be trained in how to respond when system
failures do occur. They must be prepared and
equipped with the right tools and resources
to be able to respond to at-risk situations and
prevent medical errors or sentinel events from
occurring.20
In an HRHO, effective teams are key to op-
timal functioning. Characteristics of effective
teams in HROs include (a) outstanding team
leadership, in which team members have a
clear vision and purpose and the roles of each
team member are clear; (b) backup behavior,
which is when team members are capable of
self-correcting behaviors and feedback is pro-
vided regularly; (c) mutual performance mon-
itoring, where team members understand and
monitor each other’s roles; (d) communica-
tion adaptability, in which communication is
clear, often, and enough; and (e) mutual trust,
in which each member of a team trusts each
other’s intentions.21
A CULTURE OF PATIENT SAFETY
Although a culture of patient safety is a ne-
cessity in an HRHO, it is often challenging to
define and measure a safe culture. In a com-
prehensive literature review whose purpose
was to organize the properties of a safety cul-
ture, Sammer and colleagues3 identified the
following as essential components: (a) lead-

ership, in which key leaders are aware that
the health care environment is one of risk
and seek to reduce risk by aligning the vi-
sion/mission, staff competencies, and fiscal
and human resources with frontline care; (b)
teamwork, which includes collaboration and
cooperation among leaders and staff mem-
bers; (c) evidence-based, in which practices
are based on the best evidence to improve
standardization and reduce variation; (d) com-
munication, in which the environment facili-
tates each member to speak up on behalf of a
patient; (e) learning, in which the health care
system learns from its mistakes and seeks to
continually improve its processes and perfor-
mance; (f) just, in which the culture is one
that sees errors as system failures rather than
individual failures; and (g) patient-centered,
in which the care in the health care system
is centered around the patients and family
members.
LWW/NAQ NAQ200184 March 1, 2012 23:19
JUNE 2012
MEASUREMENT OF PATIENT SAFETY
Data-driven decisions are an important part
of an HRHO; therefore, careful monitoring

of patient safety is essential. Scorecards can
be used to track patient safety outcomes. For
example, Pronovost and colleagues1 describe
the framework for a patient safety scorecard
in an HRO that includes the following: (a)
How often do we harm patients (measured
by the number of medical errors or sen-
tinel events, such as catheter-associated blood
stream infections)? (b) How often do we pro-
vide interventions that patients should receive
(eg, the proportion of patients who receive
evidence-based interventions)? (c) How often
do we learn from defects? (eg, the propor-
tion of months that each patient care area
learns from its mistakes and includes root-
cause analysis along with revised policies to
prevent future errors); (d) How well have we
created a culture of safety? (eg, the percent-
age of patient care areas in which 80% of the
staff report a positive safety and teamwork cli-
mate). The framework and concepts from an
HRO are helpful in developing HRHOs. How-
ever, it should be remembered that, although
concepts from HROs can be used to improve
processes and outcomes in health care sys-
tems, they are not meant to replace safety
and quality initiatives that are already be-
ing implemented and successful in improving
outcomes.
RECOMMENDATIONS FOR LEADERS TO
CREATE HIGH-RELIABILITY CULTURES
A variety of strategies can be implemented
by leaders to create HRHOs. The first strat-
egy is to conduct transdisciplinary team train-

ing in which all managers and staff are taught
about HROs and methods to achieve them.
The second strategy is deliberately designing
key care processes to reduce risk and en-
sure high-quality care. Third, it is important
that all members of the team understand its
key processes. Fourth, it is critical to error
proof the organization. The fifth strategy in-
volves process standardization (ie, uniformity
in how care is delivered to patients).21 Finally,
as part of building an HRHO, it is critical
to cultivate a culture of EBP in which there
is a never-ending spirit of inquiry within ev-
eryone in the organization regarding how to
improve the quality, safety, and efficiency of
care.
EVIDENCE IS KEY IN BOTH
HIGH-RELIABILITY ORGANIZATIONS
AND EVIDENCE-BASED PRACTICE
CULTURES
Careful tracking of data along with
outcomes monitoring of key system and
patient outcomes is critical in an HRHO.
Furthermore, external evidence from both
rigorous research and internal evidence (ie,
data that are generated from practice, pa-
tients, and outcomes management) is criti-
cal to formulating the best practices to im-
prove the quality and safety of care. In an
HRHO and an EBP culture, leaders engage
in evidence-based management and clinicians
engage in EBP. Evidence-based practice is a
problem-solving approach to the delivery of

care that integrates the best evidence from
well-designed studies with a clinician’s ex-
pertise, including clinical wisdom, reasoning,
patient history, physical data collection and
resource utilization, and a patient’s prefer-
ences and values to make decisions about the
type of care provided.22 The ultimate pur-
pose of EBP is to improve health care qual-
ity and patient outcomes and reduce hospital
costs. When evidence-based care is delivered
within an EBP culture and a context of car-
ing, the best patient outcomes are achieved
(Figure 1).
THE STEPS OF EVIDENCE-BASED
PRACTICE
To build HRHOs and EBP cultures, clini-
cians should learn and consistently implement
the steps of EBP, which include (1) cultivate
a spirit of inquiry; (2) ask clinical questions in
PICOT format, which stands for patient pop-
ulation of interest, intervention of interest,
LWW/NAQ NAQ200184 March 1, 2012 23:19
Clinical decision
making

Quality
patient
outcomes
Research evidence
and evidence-based
theories
Clinical expertise (eg, evidence
from patient assessment, internal
evidence, and the use of health care
resources)
Patient preferences
Context of caring
EBP organizational culture
Figure 1. The evidence-based practice (EBP) paradigm.
Copyright 2003 Melnyk and Fineout-Overholt.
comparison intervention or group, outcome,
and time (eg, In intubated patients in the ICU
(P), how does early ambulation (I) vs delayed
ambulation (C) affect episodes of ventilator-
associated pneumonia (O) while in the ICU
(T)?); (3) search for the best evidence; (4) in-
tegrate the evidence with clinical expertise
and patient preferences to make the best clin-
ical decision; (5) evaluate the outcome(s) of
the EBP change; and (6) disseminate the out-
comes so that other patients can benefit. In
EBP, if there is enough high-quality evidence

from research to change practice, the prac-
tice is changed and outcomes are monitored
to support that the change in practice based
on research produces positive outcomes in
the real-world setting. If there is not enough
high-quality evidence to change practice, ex-
ternal evidence must be generated through
rigorous research or internal evidence pro-
duced through quality improvement or out-
comes management projects. High-reliability
health care organizations begin with leaders
and point-of-care providers who take the time
to think and reflect about the care that is be-
ing delivered and continually ask how it can
be improved, which is analogous to cultivat-
ing a spirit of inquiry or step 0 in the EBP
process.
CHARACTERISTICS OF BOTH
ORGANIZATIONS AND EVIDENCE-BASED
PRACTICE CULTURES
There are many similarities between build-
ing an HRHO and an EBP culture. Character-
istics of both are included in the Table. Both
HRHOs and EBP cultures work to obtain the
highest levels of health care quality, safety,
and patient outcomes. Outcomes monitoring
Table. Characteristics of Both High-
Reliability Organizations and Evidence-
Based Practice Cultures
Commitment to delivering high-quality care
and patient safety and reducing costs

Strong leadership
Emphasis on process and systems design
Transdisciplinary teamwork
Effective communication
Delivery/standardization of best practices
and policies
An environment that promotes a spirit of
inquiry and continuous learning
Focus on continual process improvement
Outcomes monitoring/evaluation
LWW/NAQ NAQ200184 March 1, 2012 23:19
JUNE 2012
is a critical strategy in both HRHOs and EBP
cultures because outcomes reflect the impact
that is being made on health care quality, pa-
tient outcomes, and system outcomes.
BARRIERS TO AND FACILITATORS
OF ADVANCING HIGH-RELIABILITY
HEALTH CARE ORGANIZATIONS AND
EVIDENCE-BASED PRACTICE CULTURES
There are multiple barriers to leaders and
clinicians succeeding in developing an HRHO

and an EBP culture. Some of the major barri-
ers include (a) lack of knowledge and skills in
both HRHOs and EBP; (b) perceived lack of
time; (c) lack of organizational/administrative
support; and (d) educational programs that
continue to teach the “traditional way” with
a focus on producing research instead of us-
ing evidence to improve practice; and (e) lack
of mentorship.23-26 Conversely, facilitators of
building HRHOs and EBP cultures include
(a) knowledge and skills of HRHOs and EBP,
(b) beliefs that these types of organizations
and cultures improve care and patient out-
comes; (c) beliefs in the ability to implement
EBP and key concepts of HRHOs; (d) men-
tors who are skilled in EBP and HRHO con-
cepts; and (e) administrative/organizational
support, including leaders and managers who
model important behaviors related to EBP and
HRHOs.22,27,28
THE ARCC MODEL AS AN EXAMPLE OF
HOW BUILDING AN EVIDENCE-BASED
PRACTICE CULTURE FACILITATES A
ORGANIZATION
Use of the EBP paradigm assists organi-
zations in achieving high reliability. There
is evidence to indicate that implementation
of evidence-based care helps reduce defects
in care processes, improves quality of care
and patient outcomes, standardizes care, de-
creases variations in care, increases efficiency
and decreases health care costs.1,22,25,29,30

The ARCC (Advancing Research and Clin-
ical practice through close Collaboration)
model is a systemwide model that can be used
by health care systems and hospitals for sus-
taining EBP and facilitating an HRHO (Figure
2). The ARCC model was first conceptualized
in 1999 as part of a strategic planning process
at a major medical center to rapidly integrate
research findings with clinical practice for the
ultimate purpose of improving quality of care
and patient outcomes. Four assumptions are
inherent in the ARCC model: (1) There are
barriers and facilitators of EBP for individu-
als and within health care systems. (2) Barri-
ers to EBP must be removed or mitigated and
facilitators put in place for both individuals
and health care systems to implement EBP as
standard of care. (3) In order for clinicians to
change their practices to be evidence-based,
cognitive beliefs about the value of EBP and
confidence about the ability to implement it
must be strengthened. (4) A culture of EBP
that includes EBP mentors (ie, clinicians with
advanced knowledge and skills in EBP, men-
torship, and individual as well as organiza-
tional change) is necessary to advance and
sustain evidence-based care.31
Implementation of the ARCC model be-
gins with an assessment of the culture and
readiness for EBP, which allows for the iden-
tification of strengths and limitations within
the health care system that either facilitate or
hinder the development of an EBP culture.
Next, a cadre of EBP mentors is developed

whose role is to address the limitations, en-
hance the strengths in the health care system
to build an EBP culture, and work directly
with point-of-care clinicians in implementing
and sustaining EBP. The ARCC model con-
tends that, when clinicians are mentored in
EBP, their cognitive beliefs about the value
of EBP and their ability to implement it are
strengthened, which results in greater imple-
mentation of EBP. Furthermore, when EBP is
implemented, there is improvement in patient
outcomes and clinician group cohesion and
job satisfaction, which ultimately results in
less turnover within the organization. To date,
several studies have been conducted that have
supported relationships among constructs in
the ARCC model.28,32,33,34
LWW/NAQ NAQ200184 March 1, 2012 23:19
Figure 2. The ARCC model for systemwide implementation and
sustainability of evidence-based practice
(EBP) can facilitate a high-reliability health care organization.
Copyright 2005 Melnyk and Fineout-Overholt.
aScale developed. bBased on EBP paradigm and using the EBP
process.
Implementation of the ARCC model is ac-
complished through a 12-month program to

prepare a cadre of EBP mentors who then
work with direct care staff to implement and
sustain EBP throughout the health care sys-
tem. Evidence-based practice mentors are typ-
ically advanced practice nurses or transdisci-
plinary professionals or clinicians with bach-
elor’s degrees. A series of 6 workshops with
8 days of educational and skills building ses-
sions are conducted over the yearlong ARCC
program, which is focused on implementing
the 7-step EBP process and necessary strate-
gies for building an EBP culture. Major con-
tent of the ARCC workshops includes (a) EBP
skills building; (b) creating a vision to mo-
tivate a change to EBP; (c) transdisciplinary
team building and effective communication;
(d) mentorship to advance EBP; (e) strate-
gies to build an EBP culture; (f) quality im-
provement processes; (g) data management
and outcomes monitoring/evaluation; and (h)
theories and principles of individual behav-
ior change and organizational change. Before
the first workshop, a baseline assessment is
conducted to assess the clinicians’ EBP be-
liefs, EBP implementation, organizational cul-
ture and readiness for EBP, job satisfaction,
and group cohesion. Patient data on problems
identified for improvement by the clinicians in
the ARCC program are also collected and ana-
lyzed. Each team that is attending the series of
workshops implements an EBP implementa-
tion project during the course of the 12-month
program focused on improving quality of care,
safety, and/or patient outcomes. Examples
of projects and outcomes from the most re-

cent implementation of the ARCC model at
the Washington Hospital Healthcare System,
a 355-bed community hospital system in the
Western region of the United States, include
the following: (a) Early ambulation in the ICU
LWW/NAQ NAQ200184 March 1, 2012 23:19
JUNE 2012
resulted in a reduction in ventilator days from
11.6 to 8.9 days and no ventilator-associated
pneumonias. (b) Pressure ulcer rates were re-
duced from 6.07% to 0.62% on a medical sur-
gical unit. (c) Education of patients with con-
gestive heart failure led to a 14.7% reduction
in hospital readmissions. (d) Seventy-five per-
cent of parents perceived the overall quality
of care as excellent after implementation of an
evidence-based family-centered care program
compared with 22.2% before implementation.
MAJOR FACTORS INFLUENCING
ADOPTION OF EVIDENCE-BASED
PRACTICES
There are a number of factors that can in-
fluence the adoption of EBPs. Some of these
factors include (a) the characteristics of the
EBP (eg, the strength of evidence to support

the practice, ease of administration, and cost);
(b) characteristics of the clinician (eg, the un-
derstanding and cognitive beliefs/confidence
to implement it and self-efficacy; (c) the envi-
ronment and culture of the organization; and
(d) the process through which the change
is implemented (eg, consensus building and
use of EBP mentors and opinion leaders).35,36
These same factors are likely to exist when ap-
plying concepts from HROs in health care or-
ganizations. For clinicians to implement best
practices and concepts from HROs, it must be
made easy and fun as they are overburdened
with patient loads and competing priorities.
In addition, routine recognition and apprecia-
tion for efforts should be built in on a regular
basis to recognize individuals and teams for
their efforts. Furthermore, building EBPs and
concepts from HROs into electronic medical
records may help improve quality of care and
patient safety, but too many reminders may
lead clinicians to ignore them.
CONCLUSION
Concepts from HROs are being built into
health care systems both to improve quality
of care and patient safety and to improve ef-
ficiency and reduce health care costs. Sub-
stantial overlap exists in building HRHOs and
EBP cultures. Implementation of the ARCC
model for systemwide implementation and
sustainability of EBP can assist organizations
in achieving high reliability.

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