Hello. I'm Kathleen Stevens, a Professor at the University of Texas Health San Antonio. I've been a pioneer of evidence-based practice for a while, because of my belief that it's crucial to transform health care with the research that we discover. Our patients will enjoy better outcomes when we implement that research into practice. Hello. My name is Ethan Schuler. I'm an Acute Care Nurse Practitioner at Boston Children's Hospital in the Medical-Surgical ICU. I am also the Chair of the Evidence-based Practice Subcommittee at Boston Children's Hospital. Today, I have the pleasure of introducing Dr. Kathleen Stevens, Professor of nursing at the University of Texas Health, San Antonio. Dr. Stevens served for 15 years as founding director of the Academic Center for Evidence-Based Practice and pioneered the field. The Center of Excellence and Improvement Science Research Network generated over 12 million to advance evidence-based quality improvement and patient safety. She initiated and guided the annual Summer Institute on Evidence-Based Practice, a national interdisciplinary conference. Dr. Stevens serves on the Board of Directors of the Association for Clinical and Translational Science. She is a fellow of the Academy of Nurse Educators and American Academy of Nursing, Episteme Laureate in Nursing and named into the International Nurse Researcher Hall of Fame. Dr. Stevens, welcome to OPENPediatrics. We are so thrilled to have you here today. I like to get started by asking a question. Could you tell me a little bit about what prompted you to develop this Stevens Star Model? Well, Ethan, it's a joy to be here. It's my pleasure to share the story about the Star Model. It happened that I was a pediatric nurse and became very interested in research. And when I did-- I found out that it wasn't the day-to-day hand touching of nurse to patient. But it was a very extended kind of delayed gratification. And it occurred to me that research is just so important. But it's a delayed gratification. It takes so long to do without it moving to help patients with their outcomes. So I began thinking about what it would take to move research into direct patient care to produce the outcomes we intended. So the Star Model was born out of that passion for moving research into practice. Can you give us some historical context about how that came to be? Evidence-based practice was considered, perhaps, a suspect for being a fad back in the 1999 era. However, it was really solidly galvanized when the Institute of Medicine published a report on the errors that were made in health care. To Err is Human was a shocking revelation of how many people were harmed by the very health care that they sought to solve their health issues. And right after that 1999, 2000 publication, the Institute of Medicine published a report that became a blueprint for how to transform health care using six principles. It's called Crossing the Quality Chasm. And the six principles are to generate a health care delivery system that was safe, timely, effective, evidence-based, equitable, and patient-centered. So those S-T-E-E-E-P principles still resonate, although, that report came out in 2001. And as I was working in the field, pioneering, believing in evidence-based practice, because, as I said, research is just too tedious not to make it have a payload for the patient. It occurred to me that the idea that was promoted in chapter 6 of Crossing the Quality Chasm on evidence-based practice really was worthy of making it reachable by most health professions and certainly in nursing. So the Star Model came about in thinking about what works in health care. There was an IOM 2008 publication, saying, well, what works in health care, we really need to know, because those are the interventions to carry forward for our patients and family. Then a couple of more reports on what works highlighted systematic reviews and clinical practice guidelines, which are part and parcel of the essence of evidence-based practice and therefore, the Star Model. So in the early days, those reports didn't really exist. And I was connecting people with the idea of moving research to practice and kept listing the same five steps until it occurred to us as a group that, perhaps, this could be a five-point star. The Stevens Star Model has five points. Can you walk me through them? The five points of the Stevens Star Model identify the transformation that knowledge has to undergo in order to inform clinical decisions. So, well, that's where we want to go with our original research on point one of the star. So that's the first point is discovery research. The second point is, now that we have multiple research projects on the same topic of, does this intervention produce the intended outcome, we need to amass it and synthesize it or summarize it to be helpful. For the third point of the star, which is, clinicians sit down and look at the massive evidence the summary that was generated through a systematic review and where there is missing evidence, missing research, clinical expertise is added there. And the output of that particular process is a clinical practice guideline that is based on the best available evidence combined with the clinical expertise that fills in the gaps. Moving to point 4 of the star, we have this wonderful program, now, and recommendations that we know this works in health care. But bringing it to the front line and thinking about, how do we get it implemented or integrated into our usual practice? So point four of the star is called practice integration. And the idea is to hardwire this new practice into the kind of care that we give with high excellence to our patients. And, of course, the fifth point of the star is to think about, did we produce the impact? Did we produce the impact that we wanted in individual clinicians providing the care, in patients that receive the care and moving their health outcome to a better status? And in the organization, understanding that this learning process, as an organization, is part and parcel of their excellence of the services that they provide to the community. I'd like to stop now and ask our colleagues around the world a question. In your response, please leave your city and country location. The question is, what helps facilitate evidence-based practice in your facility? Describe an approach you have found successful for implementing a change in your institution. What are some effective ways that a bedside nurse who's going through this process of knowledge transformation can do in order to be an agent of change? Evidence-based practice in our discipline is, number one, a shared activity across disciplines, because our practices are interwoven. And since evidence-based practice has been studied in the processes for producing discovery research or evidence summaries, or translation to guidelines, those processes have been stabilized. So carrying the evidence-based practice forward into practice integration represents a new field-- a new field that's been spurred on by the clinical and translational science awards here out of the National Institute for Health. And the National Institute for Nursing Research is part of that activity. We know less about how to change that behavior, because when you show up in the clinical practice setting, although your counsel has built a very strong evidence-based clinical practice guideline, it represents a change in behavior for the clinician. We're in a high-risk business. And we like to hold onto something that we think works. So showing up with the best evidence takes a leap of faith into understanding how that evidence was produced. And that becomes a transparent activity. And as the frontline provider looks at that transparency and says, yes, I know that we're following the best process for taking evidence and moving it into recommendations so that I can integrate it into care becomes a real high trust type of activity that helps a great deal. But implementation strategies that work include things, like, setting a scientific standard for this is the way we will do this and implement it, packaging that clinical practice guideline to where it's accessible to the clinician. And the clinician says, OK, I will implement it now-- show me how. So a champion is very often a strategy that's used for practice facilitation. Setting the standard and getting everybody to agree on the team that this is the standard provides an opportunity for a second type of intervention. And that is audit feedback. We've set the standard. We've looked at your behavior. Let's reflect on those clinical decisions. Are they matching our standard? So that's audit feedback. And it offers an opportunity for reflective practice and self-correction to that scientific standard. Let's see. Another way is the necessary education to have a person's thinking change from the old practice to the new practice. But that doesn't get the action just yet. So sometimes that championing and academic detailing is an important part of changing practice. Dr. Stevens, can you speak about the key stakeholders that are involved who would utilize knowledge to affect health care outcomes? Absolutely. The change agent has to interact with probably four levels of stakeholders. The first one, of course, is the individual clinician. They have a lot at stake in terms of giving up their old practice for the new. The next is the care team. And that care team adjusts and bounces off of each other as a microsystem to hold steady the practice that is in place. The third level is the organizational level that has the policy and what's the procedure followed. And then the fourth one is this external environment of policy payers, the community expectations. So those four levels all have an impact on the change and receive the change in a different way. How important is a team-based approach and change implementation? The delivery of health care services requires a team approach because we deliver it as a team. Each of us is embedded in a complex adaptive system that requires us to think broadly and in terms of system, and not only microsystem, but macrosystem. So teaming across all stakeholders is crucial if something is changed that affects pharmacy. Then they need to be involved. And sometimes we forget housekeeping is also involved. And sometimes we forget, you know, all these different facets of our complex adaptive system that when we change one thing, it sometimes affects another aspect. And so the idea of complexity theory is one that is fairly new in nursing. Systems thinking is fairly new in nursing. And so it's really, really exciting to think about what disciplines can inform us as we move forward in our complex adaptive systems. And in our system thinking, people like systems engineers, can be very helpful. Industrial engineers are all about the process and flow through. And there are many questions about improving care that we can turn to health economist to help us with the return on investment. So you see, as we think about what kind of bridge we need to build to get research into practice through this system environment that the complex adaptive system is a huge part of the attention that we need to pay as change agents. As a collaborative-- It is collaborative. It requires a team that is totally focused. When they come together as a team, not that that's their whole life. But that's their work on this particular project during that particular time that they all share and lift toward the same goal. And so that's the shared mental model that's so important in change management. Can you talk about the state of where you see implementation science five, ten years down the road from now? I would be happy to project-- what I see implementation science evolving into-- I believe in the United States that the National Institutes of Health, Clinical and Translational Science Award Program has set in motion an awareness for dissemination and implementation. And in order to build principles that we can employ on point four of the star, those integration principles, the implementation research can evolve and test what strategies work in promoting uptake of that evidence-based guideline. So the idea of building a science is one that starts out pretty messy. It's everybody's labeling different things. There are over 60 theories that have been advanced on different parts of the process of implementation. And I know that, as I've seen evidence-based practice become consolidated, so will implementation research become consolidated into this science of sound principles. And it is starting out as a beautiful interprofessional aspect of health care that people from a number of disciplines come together. And the discipline playing field is really leveled at several of the conferences that are promoting and advancing dissemination and implementation. So in the meantime, things, like, theories are being developed. There's one theory that is rising above all the rest. And it will become more commonly used, not that there's no room for another one because there are different aspects, as you can see, of implementation. There are new competencies that are being agreed upon in terms of, these are the competencies that we need to conduct implementation research. It's a new field of research. And so our scientific workforce capacity needs to be brought up to the point where we can produce and write great grants and generate those strategies that have been evaluated that are effective. In addition to the competencies for implementation research, there's implementation practice, I think, that can evolve in terms of the issues that we've talked about today. What does the frontline, middle management, supervisory, overall arching policy people, what do they need to understand about using the principles from that science, because that's what science is for. It explains how things work. And so if we can build that science and turn to practitioners, clinicians, administrators and say, here's how it works. You press it here. And you can cause that to happen. You do an audit feedback mechanism. And you can get 60% certainty that you're going to get a change in behavior. Then we've really delivered what needs to be delivered to clinicians who are transforming health care delivery. So in the future, implementation science will grow to be a more crystallized science. And right now, we're just great explorers in finding it and creating and inventing new designs and new statistical approaches. So the field is moving quickly. I think that in 10 years, we'd have a solid science to deliver to clinicians and practitioners who want to apply the science. You've highlighted how critical it is to get buy in from providers and clinicians and members of the health care team. How critical is it to also have input from the patient? The patient is included in evidence-based practice in several places, as you do academic practice partnering clinicians and providers and patients and parents are part of even that point one of the star. But as it rolls around the traditional systematic review using Cochran's approach, engages patients and a broader set of academic and professional organizations. Certainly in point 3 where the guideline is being developed, your patient advocacy groups are important. But when it comes to deliver the care on point four of the star. And you show up with the best practice saying, you've come to us for services. We're matching the best practice with your particular condition. We believe this has a high likelihood of getting you to your goal of better health. It is a partnership and a negotiation with the parents and the patient of whether or not they actually want that best practice. Sometimes it's a matter of informing and changing their perception. And sometimes it's a matter of giving them options. So patient preferences really enter heavily on point four of the star. So the Stevens Star Model has been around for nearly 20 years. And you've highlighted how our health care system has evolved so much in just that short amount of time. How has your model adapted and changed over time to meet that evolving climate? It has remained surprisingly stable and the same. The first Star Model, the graphics were a little rougher. But the idea behind point one, two, three, and four have not changed. Some additional words have been added so that it communicates and is much more accessible for a quick view of transforming knowledge into practice. The biggest change, I think, conceptually that occurred was on point four, our integration. Initially, it was called implementation. And history has circled me back around to be working in the field of implementation science. But at that point, I really thought all you had to do was implement. And it comes to mind that what has to happen is a true integration, a hard wiring, a deep-seated rooting of this evidence into everyone's practice so that it becomes not evidence-based practice but the way we do things here. Now, this is our new standard. And it's embedded with science and patient preference and clinical expertise. So point four has changed just a little bit, although I'm returning to it with a new science called implementation science. And point four now is called the integration to reflect that, really, shift at a learning health care organization level and a shift in culture of being open to being nimble and transformative in our health care. It's funny that you just brought up the same word that I was just about to ask was, shifting organizational culture, because that's one of the known difficulties in trying to implement this kind of work. And so I think that you have a keen insight onto how important it is to get that buy in. So that you can use science and evidence in order to change that culture. That's a really good point. I think that we take seriously the services and what our work really is. And we become risk-averse, because human lives and human health hang in the balance. And so we tighten up around what we know works in our routines. And to loosen that up and have the trust in the evidence and the process that delivers it to the front for care, is major in terms of building that culture of trust. And how important is it to have this change but then also to go back and look at the repercussions of this change and the outcomes associated with that? So the five points of the Star Model culminate in the fifth point which is evaluation. And we know that implementing a change-- first of all, it's very painful for folks. But getting them beyond that and having the clinician satisfied with this new practice is one of those very real outcomes. Of course we want the patient and the parents and the community happy with the shift in health outcome and population outcome. And then we hope to have some kind of level of impact on policy in terms of, how do we stabilize this through our local policy and national policy? So evaluation becomes an issue of, how do we sustain the change? Part of it is return on investment because change is never cheap. And then making the change stick, you know, not floating back into old habits is all served with benchmarks and report cards. And the encouragement that, yes, this was a hard shift. And we were novices with this new practice. And it's become very productive in terms of increasing the excellence of our care, as well as the patient outcome. I'd like to turn a final time to our audience and ask a question. In your answer, please leave your city and country location. The question is, is there a standard timeline for reviewing clinical practice guidelines in your institution? If not when should they be reviewed? For a new nurse who is just beginning to delve into evidence-based practice, and somebody that may have that passion for change but doesn't necessarily know how to go about it, what words of advice do you have for someone who has this deep-seated need to be an agent of change but are just at the beginning of their journey? In part, the answer to that question is, the expert panels that I put together to define the essential competencies for evidence-based practice in nursing. And it was amazing to me out of those 83 statements, they're divided into basic, intermediate, and advanced. A number of them focused on change and change agents. One of them focused on not necessarily being what we call the leader but acknowledging that we have to have good followers, trusting followers who are aware of the process and believe in the process and will take that risk under a leader to move it forward. And today, they may be a follower. Or I may be a leader. And tomorrow, I may be a follower with a new practice. So that balance of leadership and followership is a really high-level kind of idea that new graduates can come into the clinical setting with. Can you talk more in-depth about the steps to change management? So change management really has been studied a great deal by the business field, because as businesses generate new products, new services, the aspects of having the adoption embraced is the source of their continuation. So this comes out of the business field. But there are eight change management strategies. The first is, to create a sense of urgency that this has to change. We can't proceed this way because there's impending-- there's impending harms. There's impending loss. There's impending situations that are not as good as they could be. So creating that sense of urgency is crucial to the next step of building a guiding team. There will be people that you invite in. And there will be people that are naturally drawn to the particular issue. That team, then, has some work to do in terms of getting their central point. I happen to use a yellow sticky. For any particular project and write it on the yellow sticky and keep that in front of me, it's called developing a change vision and strategy are in this field of change management. It's called a shared mental model. So having a shared mental model is essential to all group work. Or else, you'd be pulling in all different directions. Having people who aren't those early adopters really get on board in terms of buying in and understanding the benefits of the change, and what it would require in terms of their own practices is very important, and then empowering them. The supply sometimes are affected. Sometimes, it's the educational material for the patients. Sometimes, it's the physical layout. So the high reliability organization aspects really go into empowering others and celebrating those short-term wins in seeing the progress, the interim process adopted before you even get to the outcomes is really important-- badges and stars and awards and posters and announcements to underscore and hold solid to this course of change. So the short-term wins are very important. And then we all can get very excited early on. But we can't let up. You have to be relentless in change management in saying, this is good. Let's keep pushing. Is it working? Can we streamline something? Until finally, you receive at the level eight of change management, a new culture of values and practices that are totally embraced by that whole system, by that whole group, as this is the way we do things here. And it is elevated to this very high level of a standard of science. How has that change sustained over time? So change is sustained over time by reinforcement. Being pediatric backgrounds, we know about reinforcing and extinguishing behavior. So reinforcement depends on which level of the process you're at for the clinician, for the administrator. So the return on your investment of effort and attention and time and risk taking has to be seen. That return has to be seen so that it would be sustained. And that's part of being relentless. So yes, there's a dollar amount that can be attached to it. But there is also these-- I call them distant dollar amounts-- that have to do with patient satisfaction and parents returning to your services and the joy that nurses receive, and work and the decrease in the turnover of the nursing staff. So all of these things sustain that change. I'm not certain that we can always point to a single incident of, we implemented this evidence-based practice guideline. And we got all of this magnificent culture change. But it takes all of that to move to a learning health care organization and create that culture of safety, that culture of change, that culture of transformation. You bring up an interesting point in that we can affect patient outcomes. But we can also affect clinician outcomes, as well, in terms of creating a healthier work environment, leading to more job retention over time, job satisfaction, as well. And I think that's a very important point. Indeed, it is. Your own hospital has been highlighted for creating an excellent work environment for nurses. And we know from research that nurses who work in a safe environment not only where the nurse-patient ratio is a good nurse patient-ratio, but also, this acceptance of, we will have failures. Remember the first report was called To Err is Human. If we learn from those, we have to be that learning organization to go back and plug those holes so that those safety issues go away. A nurse feels safe, then. There's a safety net and the excitement of working in a place that you enjoy working in. And it leads directly underscored by research evidence into safer care provided by the staff. Dr. Stevens, you're an insightful and respected leader in this field of work. And we'd like to thank you very much for your time today. And you've really brought home how a nurse in the context of a health care organization, in the context of a national movement to improve care for our patients, and how all that is interrelated. And we'd like to thank you for all these insights that you've shared with us today that we can implement here at Boston Children's Hospital. So, thank you again for being with us today. It's been my pleasure. You're very welcome.