The paradigms of evidence-based practice (EBP) and quality improvement (QI) have evolved exponentially over the past three decades, with increasing calls for congruence between the two.1, 2 Given the growing complexity of health care and related fields, the incorporation of QI principles into EBP initiatives is urgently needed to promote efficient, synergistic approaches; continuous monitoring of outcomes; and sustainability of best practices and processes.3

This article introduces the Mountain Model, the first conceptual model designed to guide evidence-based practice quality improvement (EBPQI) initiatives. The Mountain Model integrates modern EBP and QI paradigm principles into a unified framework for nursing and other health care disciplines, with the goal of disseminating and sustaining EBPQI projects across settings.

BACKGROUND

Evidence-based medicine is generally considered the precursor to EBP. The evidence-based medicine movement, popularized by David Sackett,4 was adapted to the problem-solving approach used by nurses within the context of care as EBP.5 In recent decades, the use of EBP has expanded rapidly. Today, EBP's emphasis on incorporating supportive evidence into practice changes and decision-making to ensure high-quality care is widely accepted.6

QI uses data to improve health care quality and safety. Within the nursing profession, Florence Nightingale used epidemiological data to improve patient care and taught nurses to make timely changes to practice according to collected evidence.7 Nightingale's continuous data collection and monitoring of practice changes could be considered early QI. However, QI principles are thought to have originated in the industrial field with W. Edwards Deming, whose work became the foundation for the Plan–Do–Study–Act (PDSA) cycle widely used today to support continuous improvement.8, 9 Health care organizations have drawn from the efforts of QI pioneers and have also benefited from newer methodologies to advance the practice of nursing and the quality of health care.3

THE NEED FOR AN EBPQI FRAMEWORK

Although EBP and QI principles are frequently used to guide practice changes, EBP lacks the sustainability component of QI, and QI traditionally favors the use of internal evidence, to the exclusion of external (research) evidence.

Sustainability. EBP models focus on finding, critically appraising, and synthesizing research evidence to identify the optimal intervention to address a problem. Next, a practice or process change, policy, protocol, or guideline is developed by integrating the identified intervention with the expertise of those involved and the preferences of patients (or other groups). All involved are informed and engaged, with the expectation that the practice change will occur with the use of implementation science principles—strategies for implementing and sustaining change. Ideally, it does. But what then? The EBP model ends, and there is no systematic path for continuous monitoring of the intended outcomes. How will the people and/or organization involved determine whether the practice change was effective and will continue to work?

External evidence. External evidence is research evidence that informs the understanding of 1) a general problem (such as a disease or health care issue),10 2) a local problem (such as a population in the clinical setting with a specific diagnosis or high nurse-to-patient ratios), and 3) what has been shown to work or not work (solutions). In health care, neglecting external evidence when developing a practice change risks implementing ineffective solutions that waste resources. The Institute for Healthcare Improvement's Model for Improvement, for instance, is commonly used in clinical settings but lacks reference to external evidence.11 As nursing is a practice profession, and nurses who engage in process changes are modifying practice, what is known from external evidence (research) about a topic should inform any potential changes.

Merging EBP and QI. EBPQI—in which the components of EBP and QI function together—systematically moves from the generation of research to its application in practice, with continuous monitoring of the application to ensure the highest-quality care. Nurses and nursing students at all levels have an ongoing need for a specific EBPQI framework to address the continuous monitoring and sustainability components absent from EBP and the exclusion of foundational external evidence in QI.

LITERATURE REVIEW

Using PubMed, a search of the literature was conducted during the model development period using the terms evidence-based practice OR EBP AND quality improvement OR QI OR practice improvement AND model OR framework. Two adapted approaches to EBP and QI were found that merged specific practice improvement processes with EBP.1, 2 Levin and colleagues combined the seven steps of the EBP process with the QI approach of the PDSA cycle.2 Similarly, Halm and colleagues integrated the steps of EBP with the Lean process improvement method.1 Several other published sources addressed evidence-based approaches to improving health care quality, included citations of EBP and QI frameworks, and called for a blended approach.12-14

It was noted during the search that some recent literature uses the term “evidence-based quality improvement” (EBQI) to describe the merger of EBP and QI as a process improvement approach,15, 16 however, no EBQI models encapsulating EBP and QI principles were found.

THE MOUNTAIN MODEL FOR EBPQI

A myriad of flowcharts and decision trees have proliferated to provide pathways and organizational explanations for EBPQI work.16-19 The Mountain Model provides an umbrella framework that integrates these efforts (see Figure 1).

Figure 1.:

The Mountain Model for EBPQI

Foundation level. The Mountain Model posits external research and the evidence it does or does not provide as the base of the mountain—the foundation upon which all improvements in health and health care must be built.

EBP level. The first level above the base of the mountain is EBP (applying research, clinical expertise, and patient preference in practice). This level is compatible with the use of many EBP processes and protocols, such as the Iowa Model13 and the Advancing Research and Clinical Practice Through Close Collaboration Model.20 If one stops at this level, however, it will be hard to ascertain whether the practice change has been effective.

Internal evidence level. To create a successful and sustainable practice change, one must add internal evidence and identify outcomes or measures that show that the change has made a difference (costs, quality and safety metrics).

Purpose and aims and QI levels. Next, one must develop a clear purpose for the practice change based on the identified problem or issue and the evidence in support of the change. Additionally, to increase sustainability and continuously improve practice, EBP changes must be monitored using specific, measurable, achievable, relevant, and time-bound (SMART) goals and QI methods for implementation, evaluation, and sustainability.

EBPQI initiatives level. Working through the foundation and the first four levels of the model will produce an EBPQI initiative. The flag on top of the mountain symbolizes an important goal of EBPQI initiatives: dissemination. Expanding the impact of a successful practice change requires that the improvements and learning that occurred during the EBPQI initiative be shared so that the findings can be adapted to other contexts and settings.

AN EBPQI EXAMPLE

A nurse who works in the public health department of a rural county has received notice that the county's only hospital will no longer provide prenatal care or labor and delivery services. Pregnant people will now need to travel an additional 75 to 90 minutes to access obstetrics care at the next closest hospital, and the nurse worries that this hardship will keep many from receiving prenatal care. Because she feels strongly that all pregnant people should have access to safe, high-quality perinatal and birth services, she decides to research a feasible solution to address this problem.

Using the Mountain Model, her first step is to search for external research evidence (foundation level). She conducts a literature search using a PPCO (problem, population, change, outcome) question (see Table 1).21 PPCO is an alternative to the PICO (population, intervention, comparison intervention, outcome) question nurses can use to inform EBPQI initiatives.21 The nurse's PPCO question is: “Because the county's one OB-GYN clinic no longer offers perinatal care services (P) to childbearing people (P), what clinic alternatives exist (C) for the delivery of safe perinatal care (O)?”

Table 1. - The PPCO Framework and an Example Element Description Example Problem (P) What is the problem in general (external evidence) and specifically in the local context (internal evidence)? Perinatal care services are no longer offered at the county's one OB-GYN clinic Population (P) Who does the problem impact? Childbearing people Change (C) What has been recommended or done to address the problem? Alternatives to closed OB-GYN clinic for delivery of perinatal care Outcome (O) How are outcomes reported (measured)? Safe perinatal care

After searching research databases, the nurse critically appraises the external evidence she has found (EBP level). She learns that nurse-led models of care have been used successfully to provide prenatal care, especially in other countries.22 In the United Kingdom, for example, nurses have provided prenatal and postpartum care to patients in their homes, and this service was perceived by patients as extremely valuable.

The nurse then looks for internal evidence pertaining to the local context (internal evidence level). She finds that her county health department used to provide prenatal and postpartum care to women in their homes, but this service was discontinued years ago when the hospital obstetric practice opened. Although there are no past data on effectiveness, the nurse notes that county infant and maternal death rates were lower when this service was offered than they are now. Based on the external research evidence and this internal evidence, the nurse develops aims and a proposal (purpose and aims level) to restart the county's prenatal and postnatal home care service as a first step in addressing the area's impending lack of maternity care services.

The measurable aims developed by the nurse are as follows (see Process, Outcome, and Balancing Measures for a definition of these improvement measures):

Eighty percent of pregnant people will enroll in the prenatal and postnatal home care service (a process or fidelity measure). The county's maternal mortality rate will remain the same or improve (an outcome measure). The county's infant mortality rate will remain the same or improve (an outcome measure). Patients' satisfaction with prenatal and postnatal home care services will score a 4 or above on a 5-point scale (a balancing measure). Box 1:

Process, Outcome, and Balancing Measures

Any one of the QI frameworks (such as PDSA,11 Six Sigma,23 or Lean24) can be used along with implementation science strategies to implement and evaluate this initiative (QI level). The goal of an EBPQI initiative is to improve health and health care; therefore, dissemination is critical (EBPQI initiatives level) so that nurses facing similar situations can adapt this project's results to their own context.

In this example, there was sufficient external research evidence to support a change in practice, but if the nurse had found insufficient evidence for such a change, the Mountain Model would still have provided guidance. In that case, the nurse would have become aware at the EBP level of the need to do more research to find additional solutions to the problem. The recognition of the need to find more research evidence can occur at the QI level, too. For example, a nurse researcher may find that a practice change doesn't work in a certain setting as the research had reported it would, and this should inspire the formation of a research question for a study to determine why.

NURSES' ROLES IN EBPQI

The Mountain Model allows nurses to work together according to their level of education and expertise to achieve an EBPQI initiative (see Figure 2). At the model's foundational level, the PhD-prepared nurse is well suited to lead research endeavors in which fellow nurses contribute as team members. At the EBP level, all nurses can provide evidence-based care. At the QI level, DNP-prepared nurses are experts at leading care improvement teams, master's-prepared nurses can provide expertise in their area of clinical specialization, and other nurses can serve as champions and team members. Ultimately, the goal of dissemination is achievable by all nurses.

Figure 2.:

Nurses' Roles in EBPQI

A common critique of QI projects is that they are local, so their results are not generalizable and do not produce new knowledge with sufficient rigor to be published in the nursing literature. Best nursing practices are always of the utmost importance and relevance, and well-done EBPQI initiatives produce knowledge on best practices that is transferable to other similar settings or populations. Dissemination of this knowledge can shorten the time from research to application of the evidence or practice change.25 Furthermore, disseminating EBPQI initiatives can save health care resources, allowing organizations to choose interventions with a higher likelihood of success based on published evidence.

DISCUSSION

No model currently exists in nursing or in any other discipline to guide the merging of a relationship between EBP and QI. The Mountain Model is the first to blend EBP and QI processes with the primary purpose of informing timely EBPQI initiatives. Levin and colleagues and Halm and colleagues discussed the importance of describing the problem identified in practice and aimed to merge EBP with specific process improvement methods (such as PDSA or Lean); however, not all tenets of EBP or QI were included in these examples.1, 2

The levels of the Mountain Model ascend from the external research evidence base to incorporation of EBP with internal evidence to ensure that the proposed practice change is appropriate in the local setting. When the determination is made that a practice change is needed, a clear purpose and focused SMART aims are developed to guide the initiative. After the initiative has been implemented, QI methods guide its ongoing monitoring and sustainability, culminating in its dissemination so that it may be shared. If the change is no longer needed, the literature base will evolve and reveal a better practice. Local needs may also change. In both cases, thoughtful deimplementation should occur.

CONCLUSIONS

Through a blended EBP and QI process founded on research, the Mountain Model offers a modern approach to practice change that may strengthen practice change initiatives, increase the research–practice connection, address practice gaps, and decrease the time it takes for research findings to be adopted into practice. Nurses' timely use of the Mountain Model can clarify confusion as to what constitutes research, EBP, and QI. The model can also help nurses see where their educational preparation and professional experience best positions them to lead and/or participate in research and EBPQI teams. As this new model is untested, its use is welcome in future research and practice change initiatives, informing its ability to serve as a guiding framework for sustainable EBPQI initiatives.

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