The document discusses evidence-based wound care implementation in clinical practice and the influence of organizational models. It provides frameworks for successful implementation including the PARIHS model. Case studies show that key elements of successful implementation are receptive organizational context and culture, effective leadership, and adequate facilitation through champions and mentors at the unit level.

1. Pedro L Pancorbo Hidalgo. 2014
The influence of organizational models on
the implementation of evidence-based
wound care in clinical practise
Pedro L. Pancorbo-Hidalgo
GNEAUPP. University of Jaen (Spain)

2. Pedro L Pancorbo Hidalgo. 2014
Evidence-based healthcare
Knowledge Generation
(Research)
Evidence and knowledge
transfer
Implementation: Using evidence
in practice
Evaluation of changes and
outcomes

3. Pedro L Pancorbo Hidalgo. 2014
Evidence implementation
 Evidence implementation means:
 Changing usual clinical practice.
 Incorporating evidence into the
culture of the organisation.
 Evaluating their impact on health
outcomes.
Joanna Briggs model

4. Pedro L Pancorbo Hidalgo. 2014
Successful implementation
3 elements:
 Realisation of the implementation strategy
 Achievement and maintenance of the
targeted practice
 Achievement and maintenance of the
organisational outcomes or patients
outcomes
Helfrich at al. Implemen Sci. 2010

5. Pedro L Pancorbo Hidalgo. 2014
What are the Barriers?
Barriers Analysis
Taxonomy (BAT)
• Individual level
• Team level
• Organisation
level
• System level
• Patient level
Gifford et al. J Nurs Manag. 2013

6. Pedro L Pancorbo Hidalgo. 2014
How to implement Evidence-
Based care in organisations?
¿Como aplicar Cuidados
basados en evidencias en
las organizaciones
sanitarias?

7. Pedro L Pancorbo Hidalgo. 2014
Conceptual framework about
evidence-based practice
implementation
Promoting Action on Research
Implementation in Health Services
(PARIHS)
Kitson A. et al. Enabling the implementation of evidence-based
practice: a conceptual framework. Qual. Health Care. 1998

8. Pedro L Pancorbo Hidalgo. 2014
EVIDENCE
IMPLEMENTATION
TYPES OF
EVIDENCE
CONTEXT
IN WICH THE
CHANGE IS
PROPOSED
FACILITAT
ION ROLE

9. Pedro L Pancorbo Hidalgo. 2014
SUCESSFUL
IMPLMENTATION WHEN… .
Evidence is
robust
Context
receptive
to change
The change
process is
adequately
Facilitated
Organisation

10. Pedro L Pancorbo Hidalgo. 2014
+
CONTEXT: Setting or enviroment where
change is to be implemented
CONTEXTO. Entorno donde se van a
implementar los cambios
CONTEXT

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+
CONTEXT
Organisational
culture
the values, beliefs and assumptions
embedded in institutions and
organizations.

12. Pedro L Pancorbo Hidalgo. 2014
+
CONTEXT
Organisation
al culture
Leadership
Transformational leadership ;
Effective teamwork

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+
CONTEXT
Organisational
culture
Leadershi
p
Evaluatio
n
Feedback on individual, team and system
performance

14. Pedro L Pancorbo Hidalgo. 2014
SUCESSFUL
IMPLMENTATION WHEN… .
Evidences
are robust
Context
receptive
to change
The change
process is
adequately
Facilitated
FACILITATION
“One person makes
things easier for others”

15. Pedro L Pancorbo Hidalgo. 2014
So, for successful Implementation is
needed:
 Receptive context
 Strong organisational culture
 Adequate leadership
 Evaluation of the outcomes
 Facilitation (Enablers)
 Support and commitment from the Management
 Policy revisions
 Monitoring of clinical outcomes

16. Pedro L Pancorbo Hidalgo. 2014
Wound care
Some cases of successful guidelines
implementation
What are the Key Elements?

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Leadership
• Leadership has been found to be
the only predictor of sustained
use of clinical guideline
recommendations. (Davies et al.
2006. Canadian Health Service
Research)

18. Pedro L Pancorbo Hidalgo. 2014
Leadership
 Definition:
 “The process of influencing others to understand
and agree about what needs to be done and how
to do it, and the process of facilitating individual
and collective efforts to accomplish shared
objectives”
Yukl , GA .2006. Leadership in organisation. 6th ed

19. Pedro L Pancorbo Hidalgo. 2014
Gifford et al. Implementation
Science. 2008

20. Pedro L Pancorbo Hidalgo. 2014
Gifford et al. Implementation
Science. 2008
Relations-oriented:
Supporting, developing personal skills,
recognizing others. (Increase mutual
trust)

21. Pedro L Pancorbo Hidalgo. 2014
Gifford et al. Implementation
Science. 2008
Change-oriented:
Integrating a vision, creating a sense of
need to change

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Gifford et al. Implementation
Science. 2008
Task-oriented:
Clarifying roles, Monitoring
performance, Providing resources

23. Pedro L Pancorbo Hidalgo. 2014
Focus on patient safety:
Pressure ulcers / Postoperative wound
infections
Multilevel Quality Collaborative project
 Leadership programme for hospital executives
(physicians and nurses). 24 Dutch hospitals
 Systematic strategy of diffusion and sustainability
 Sharing experience of the process of change
through network meeting.
 Plan – Do - Study-Act cycle at unit and hospital
level.
Dückers et al. Implementation Science.
2011.

24. Pedro L Pancorbo Hidalgo. 2014
Plan – Do – Study – Act cycle
 Strategy begins with
implementation of projects
in few pilot units (PDSA)
 If targets achieved or
substantial improvement:
 Results are used as
baseline for other units
(new norm) (planning and
control cycle at hospital
level)
 Connection between
micro (units) and meso
(hospital) levels.

25. Pedro L Pancorbo Hidalgo. 2014
Improving Foot Ulcers Care through
Leadership
Implementation of the
RNAO guideline for
care of foot ulcers
(diabetes)

26. Pedro L Pancorbo Hidalgo. 2014
Implementation of the RNAO guideline
for care of foot ulcers (diabetes
4 nursing homes Ontario ( Canada)
 Leadership strategy (intervention) 12
weeks. For managers, supervisors,
resource nurses. In addition to usual
implementation strategy.
 Educational materials printed.
 Interactive workshop.
 3 post-workshop teleconferences. networking
Gifford et al. Implementation Science. 2008

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Foot care guideline
 Recomendations on:
 Glycemic control
 Foot circulation
 Infection
 Foot sensation
 Footwear pressure /deformities
 Ulcer location
 Ulcer length and width
 Ulcer depth

28. Pedro L Pancorbo Hidalgo. 2014
Organisational level barriers
 Poor exchange of information within team
 Resistance to new forms and care plan
 Lack of equipment
 Inefficient processes
 Limited number of nurse specialists
 Restriction in nurses’ scope and practice

29. Pedro L Pancorbo Hidalgo. 2014
Implementation strategies
 Team level
 Creating channels for communication amongst team
 Involve champions and change agents
 Clarify roles
 Performance appraisals
 Organisational level
 Equipment supply
 Modify policies and procedures
 Mix of specialist staff in organisation
Gifford et al. J Nurs Mang 2013

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Facilitation
• Changing organisational structure
• Making things easier

31. Pedro L Pancorbo Hidalgo. 2014
Improving Leg Ulcer Care through
facilitation
 Leg-ulcer care in the community
 Implementation of a new model:
 Setting: Ontario (Canada)
 Change from traditional model (based on individual MDs’
orders) to a Nurses-led model (primary nurses with team)
 New model support guideline-driven practice.
 Outcomes:
 Healing rates improved from 23.1% (before) to 55.6% (after)
 Use of compression: from 43.9 % (before) to 85.3 % (after)
Harrison MB et al. Leg-ulcer care in the community, before
and after implementation of an evidence-based service.
CMAJ. 2005.

32. Pedro L Pancorbo Hidalgo. 2014
Improving Leg Ulcer Care through
facilitation (effective pathways)
 Leg ulcer care (venous and foot ulcers)
 Setting: Queensland (Australia)
 2-phases study: retrospective and prospective.
 Guidelines were poorly implemented before (e.g. Only
31% had an ABPI)
 New pathways: Clinic led by a Nurse
Practitioner
 Outcomes:
 Lesser use of resources: 2-3 visits/week to 1 visit/week
 Better outcomes: Ulcer duration: 22 weeks (before) to
12 weeks for healing (new)
Edwards E. Et al. Health service pathways for patients with chronic
leg ulcers: identifiying effective pathways for facilitation of evidence
based wound care. BMC Health Serv Res. 2013.

33. Pedro L Pancorbo Hidalgo. 2014
Improving Pressure Ulcers prevention
through Facilitation (wards champions)
 Setting: Acute public teaching hospital in
Melbourne (Australia). 9 years study.
 Programme key elements:
 Organisational changes: PU risk assessment and
prevention checklist integrated in daily workflow
 Injury prevention Nurse leader (deliver staff education)
 Ward champions (promoting the use of the
programme)
 Outcomes:
 HAPU prevalence decrease from 12.6% (2 yrs prior) to
2.6% (6 yrs post)
Barker AL et al. Implementation of pressure ulcer prevention best
practice reommendations in acute care: an observational study.
Int. Wound. J. 2013

34. Pedro L Pancorbo Hidalgo. 2014
Improving Pressure Ulcers prevention
through Facilitation (Resource Nurses)
 Outcomes: 77% reduction in
hospital-adquired PU (2009
to 2012)
 Saving cost around
US $ 500.000 each year
Beinlich N, Meehan A. JWOCN. 2014.
Setting: Acute Hospital (USA)
• Multi-disciplinary program: Resource nurse for PU
prevention (1 for each unit) plus
• Unit champions
• Specific training
• Preventive equipment

35. Pedro L Pancorbo Hidalgo. 2014
Some conclusions
 Individual clinicians should not be the only
responsible for evidence and guideline
implementation
 Healthcare organisations have to be actively involved
 Organisations should have a plan or framework for
evidence implementation.
 Context and culture of the organisation should be
receptive to change
 Effective leadership is one of the most powerful ways
to make changes
 Facilitation (at unit level, like champions or mentors) is
needed for clinicians.

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