The JBI Practical Application of Clinical Evidence System (PACES)
Interview with Professor Alan Pearson by Ashley Porter
If you printed one A4 page from every site listed under "health" on the internet and placed them side-by-side on the bank of the Amazon River you could go up and down this geographical splendour 1300 times.
This astonishing wedge of trivia highlights the flood of information mankind has discovered and stored since 1974 when Americans Robert Kahn and Vinton Serf published the first protocol leading to the invention of the internet.
It corresponds with western trends of living longer because of advancing surgical techniques, pharmaceutical discoveries, and consumer health campaigns.
But if we are so smart, why are aged-care residents still falling because handrails are placed illogically on bathroom walls, and why do pressure sores remain prevalent in so many intensive care units?
The problem is that clinicians worldwide live in a web of stress. They don't have time to gather and compare data to fix protocols because they are short-staffed and too busy with their primary duty of tending their patients.
Clinicians can now cross that river of knowledge using a new on-line resource program developed by the JBI called PACES - Practical Application of Clinical Evidence System. It is a non-time consuming, easy-to-use tool that allows them to gather data, use it to compare practices with other hospitals or health care centres, implement change, and audit their own results.
The JBI PACES is the initiative of JBI Executive Director, Professor Alan Pearson, who since completing his PhD on practice change nearly 20 years ago has made evidence-based practice his clinical passion.
The new PACES tool takes EBP to the next level ... after translating and transferring information based on the best-available evidence, it may enable clinicians to utilise it to implement change.
Professor Pearson said EBP across the world was well known and established. "Health professionals are well versed in the systematic reviews process, with significant resources and information available to them." he said.
However, little evidence exists on the most effective way to implement change in the clinical environment. This is not surprising as human beings are often resistant to change and it is for this reason that ongoing support and reinforcement to maintain evidence based practice is so vital.
"A range of interventions and approaches, including high quality information and education are essential to this endeavour.
"To promote practice change based upon the best available evidence it is necessary to identify potential obstacles within the clinical context.
"At JBI our mission is not simply the translation and transfer of evidence-based information but to improve health care delivery through effective implementation of that information. Since its inception JBI has worked tirelessly to develop high quality, effective processes and standards for evidence translation and transfer leaving implementation somewhat neglected.
"PACES represents JBI's commitment to the promotion of evidence-based practice through an effective program of utilisation.
"JBI PACES utilises standard principles of audit and feedback providing clinicians with a process of assessing their practice against the evidence.
"The audit process allows health professionals to document current practice and identify areas that may require change to be in-line with the best available evidence.
"Following the initial audit process PACES will introduce the health professional to the GRIP component of the program - Getting Research Into Practice. In a structured way GRIP leads professionals and teams through an action cycle. Literature suggests that action planning and action taking are critical to the change process.
"PACES leads professionals to formulate a plan of action as a team promoting ownership of the practice change process. This team is responsible for making decisions regarding who will be involved in the process and how.
"The audit and feedback process is not new. What is new is that PACES is automated. It is an on-line program that will prompt clinicians to follow-up actions and progress through the change process.
"Previously clinicians were encumbered by antiquated data collection processes. PACES will provide a hand-held computer that is linked to the PACES program. Clinicians will be able to collect data on the hand-held and upload information directly into the PACES program. PACES will then automatically conduct analysis and produce a publishable report comparing data from both the first and second audit. It will also allow clinicians to benchmark their health care outcomes against like facilities, departments or wards also utilising the system.
"What is different and unique about PACES is that it simplifies the audit process for clinicians." Professor Pearson said PACES was the most significant step JBI had taken in utilisation." We have made significant progress in translation and transfer, but until PACES we had not made real progress in utilisation," he said. |
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"I spend a lot of time consulting health professionals to identify their requirements with regard to closing the evidence and practice gap. It is apparent that clinicians do not object to the notion of audit and feedback, action cycle, re-audit and feedback, and benchmarking ... they recognise that this is an important element of their practice.
"Barriers include time, resources and expertise in audit tool development. The main priority is to provide patient care and clinicians are hesitant to allocate time to the auditing process in fear that it may detract from their ability to provide care.
"While we are unable to assist directly in this process, we are able to provide relevant expertise in the construction of a practical tool for data collection and analysis. JBI recognised the need for a program of utilisation that would be relevant and accessible on an international level.
"Globalisation and the information superhighway necessitated the development of a resource that could be accessed and utilised with ease from anywhere in the world. It was essential that the PACES program would be time and resource efficient. And it is.
"Not only does the program fulfil its original goal (of assisting clinicians with the utilisation of evidence-based information in practice), but it may be adapted to other fields. The tools may be clinical, but the process is a generic one that may be utilised in engineering, manufacturing industries and education.
"It is a process that encourages professionals to examine their current practices in relation to what is considered best practice and the extent to which it complies.
"PACES provides a framework for process change that enables a multidisciplinary, multi-professional approach to obstacle identification, action planning and implementation."
The development of PACES represents another tool to source and use the world's wealth of information, and Professor Pearson said it was his opinion today's health care professionals have a significant advantage to those prior to the evolution of the internet.
However, he added it was important to understand the reasons extended beyond the development of the web." You have to remember that 30 years ago knowledge was not expanding to the degree that it is now," he said.
"Historically clinical practice was based in tradition and most health practices were grounded very much on the tradition or ritual of the organisation they worked for, or how and where they trained.
"Changes in health provision stem from a significant increase in health related research and information provision not only to professionals, but consumers alike.
The issue is that whether you are a health professional or a consumer, the volume of information available is extraordinary and the demand to be informed and educated is extremely high.
"The challenges are equally frustrating for both parties and this is where organisations such as the Cochrane Collaboration and JBI have a significant contribution to make.
As with all endeavours funding and resources are at times scant, but the progress made in recent years has been considerable.
"The health care profession of the 21st century is significantly different to that of 30 years ago. It is no longer sufficient to read selected journals and visit the library on occasion. Health acuity has altered, people live longer, we have reduced mortality from cardiac problems. The expectation has been placed on professionals to base their clinical practice upon research evidence rather than traditional methods.
"At one point it was relatively easy to stay abreast of current research, as it was relatively static. This has continued to become more difficult due to the recent information explosion and increased accessibility to a vast range of international research."
According to Professor Pearson, PACES is a generic process that may be used in any quality improvement cycle in any organisation. However, he challenges those health professionals who believe their processes are critically appraised to a standard surpassing other industries.
"If you look at all of the available evidence in regard to safety and quality in the health system it would suggest that health professionals are perhaps not as critical as they should be," Professor Pearson said.
"A lot of lessons are being learned, particularly by health care professionals, from industries like aviation. They have clearly defined protocols that they follow to avoid error. A pilot will go through specific steps every time they get into the cockpit to ensure that unnecessary errors are avoided.
"However, in health care errors continue to be made that may be avoided with the introduction of and adherence to succinct clinical practice guidelines.
"There are a large number of avoidable complications or deaths that arise from medical and nursing errors. We have a tendency to excuse such errors with a claim of being a high risk industry which to some extent is true, but I think that means we are not as critical of ourselves as we should be.
"We should be attempting to establish ways of decreasing such errors. Compared with health care some industries are better at being self-critical, identifying why they make errors, and establishing systems to prevent them. Other industries are more in tune with the evidence and establishing best practice.
"At the same time, best practice is a relatively new concept in health care. The Cochrane Collaboration was only formed in 1993, and JBI in late 1996.
"Most health care centres are prepared to learn more and adapt best practices. At the base level most doctors, nurses and allied health professionals are in the job because they want to do well and facilitate good outcomes for their patients. That's why they are there. And most of them would be attempting to introduce and promote best practice in some way.
"The problem is they are busy, they have lots of priorities, and sometimes accessing the latest evidence and changing their practice is not a top priority, and nor can we expect it to be. If you are a busy General Practitioner with 20 patients waiting to see you, or if you are a nurse on a busy surgical ward where staff is limited and patients are critically ill, the first priority is to see these patients and deal with their immediate health issues.
"Referring to the evidence has to be secondary due to workload and staffing constraints. I do not think health professionals resist evidence-based practice, I think they actually strongly support it.
"JBI recognises the issues facing clinicians and other health professionals, by providing easily accessible evidence-based information in various forms. Now with PACES, JBI are also providing a simple, streamlined process to promote evidence utilisation. JBI aims to provide clinicians with the support they need to improve their practice."
The JBI Practical Application of Clinical Evidence System (PACES) is a new audit based program developed by the Joanna Briggs Institute designed to meet the specific needs of both clinicians and quality improvement staff in health care organisations.
The program involves the collection of data, relevant to a topic chosen from the Joanna Briggs' extensive clinical information database.
Using predetermined audit indicators, baseline data is collected either manually from a printout, or using a specially designed hand held computer called the PACESmate.
This data is then fed back into the PACES program for evaluation, report and feedback. If the audit shows a less than perfect compliance with the indicators, an online generic work plan (the "Getting Research Into Practice or GRIP" module) assists the user in problem identification, action planning and action taking to improve compliance with the audit indicators, prior to commencing a follow up, post action audit.
The audit team then has the opportunity to compare the pre-action/intervention results. This process can be repeated until the team is content with the results.
Also available is an on-line facility to submit data to JBI for clinical benchmarking against like-institutions, and an opportunity to join a clinical practice benchmarking group.
PACES will be accessible online to JBI members via the website at www.joannabriggs.edu.au