evidenced base Discussion: Developing a Culture of Evidence-Based Practice As your EBP skills grow, you may be called upon to share your expertise wi -

evidenced base
Discussion: Developing a Culture of Evidence-Based Practice
As your EBP skills grow, you may be called upon to share your expertise with others. While EBP practice is often conducted with unique outcomes in mind, EBP practitioners who share their results can both add to the general body of knowledge and serve as an advocate for the application of EBP.
In this Discussion, you will explore strategies for disseminating EBP within your organization, community, or industry.
To Prepare:
Review the Resources and reflect on the various strategies presented throughout the course that may be helpful in disseminating effective and widely cited EBP.
o This may include: unit-level or organizational-level presentations, poster presentations, and podium presentations at organizational, local, regional, state, and national levels, as well as publication in peer-reviewed journals.
Reflect on which type of dissemination strategy you might use to communicate EBP.

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evidenced base Discussion: Developing a Culture of Evidence-Based Practice As your EBP skills grow, you may be called upon to share your expertise wi

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JONA
Volume 37, Number 12, pp 552-557
Copyright B 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Organizational Change Strategies for
Evidence-Based Practice

Robin P. Newhouse, PhD, RN, CNA, CNOR

Sandi Dearholt, MS, RN

Stephanie Poe, MScN, RN

Linda C. Pugh, PhD, RNC, FAAN

Kathleen M. White, PhD, RN, CNAA,BC

Evidence-based practice, a crucial competency for
healthcare providers and a basic force in Magnet
hospitals, results in better patient outcomes. The
authors describe the strategic approach to support
the maturation of The Johns Hopkins Nursing
evidence-based practice model through providing
leadership, setting expectations, establishing struc-
ture, building skills, and allocating human and
material resources as well as incorporating the
model and tools into undergraduate and graduate
education at the affiliated university.

Evidence-based practice (EBP) is an essential com-
ponent of professional nursing,1,2 a crucial compe-
tency for healthcare providers,3 and a basic force in
Magnet hospitals4 and results in better patient out-
comes and higher levels of nursing autonomy.5

Fostering EBP within organizations requires strong
infrastructure, including nursing leadership and hu-
man and material resources.6-10 Several organizations
have reported on the use of EBP change models to

assist and mentor individual EBP project teams.11-14

One recent publication discusses the use of a change
model in the context of organizational change,
highlighting the establishment of an EBP committee
that is positioned within the nursing departments
administrative structure.15 Approaching the imple-
mentation of EBP as an organizational transforma-
tional change frames the approach strategically.16

After the creation and testing of a conceptual
model for EBP,17 a strategic plan was developed to
implement the Johns Hopkins Nursing EBP model
and guidelines (JHN EBP) throughout the organi-
zation. The team knew that the implementation of
EBP would require a substantial change in nursing
culture. The goal was to infuse the use of JHN EBP
into routine practice within each department. This
goal required a number of strategic objectives that
included developing EBP education programs and
Web-based resources, modifying job description cri-
teria to include behavioral outcomes for EBP, defin-
ing the origin of potential question generation, and
building nurse EBP skills and expertise (Table 1).
The EBP program was built through providing lead-
ership, setting expectations, establishing structure,
building skills, and allocating human and mate-
rial resources. The JHN EBP model and tools were
then incorporated into undergraduate and graduate
education at the affiliated university. This article
describes the strategic approach to building infra-
structure to support the maturation of EBP within
an academic medical center.

Leadership

Leadership endorsement was the initial step in
building the EBP program. Nurse administrators
are responsible for managing both human and

552 JONA Vol. 37, No. 12 December 2007

Authors Affiliations: Assistant Dean, Doctor of Nursing
Practice Studies and Associate Professor, University of Maryland
School of Nursing, Baltimore, Maryland (Dr Newhouse); Assistant
Director of Nursing, Neuroscience, and Psychiatry (Ms Dearholt);
Assistant Director of Nursing, Clinical Quality (Dr Poe), Nursing
Administration, The Johns Hopkins Hospital, Baltimore, Maryland;
Professor of Nursing (Dr Pugh), York College of Pennsylvania,
York, Pennsylvania; Associate Professor and Director, Masters
Program and Interim Director, Doctor of Nursing Practice Program
(Dr White), The Johns Hopkins University School of Nursing,
Baltimore, Maryland.

Doctor Newhouse was Nurse Researcher at Johns Hopkins
Hospital and Associate Professor at Johns Hopkins University
School of Nursing.

Doctor Pugh was an associate professor at the Johns Hopkins
University School of Nursing.

Corresponding author: Dr Poe, The Johns Hopkins Hospital,
Department of Nursing Administration, 600 N. Wolfe St., ADM
220, Baltimore, MD 21287 ([emailprotected]).

material resources necessary for the successful
implementation of the EBP program. Leadership
is critical to build organizational readiness for
change.16,18 This nursing department is part of a
highly decentralized organization. A director of
nursing, an administrator, and a physician director
lead each department with responsibility for the
service area. Because of their accountability for
resources, it was essential that the directors of
nursing were committed to the EBP implementa-
tion goals. The strategic plan was approved by
leadership and the governance committees (stan-
dards of care [SOC], standards of practice, nursing
clinical quality improvement, staff education, and
research committees) and was then incorporated
into the committee structure.

Establishing the Structure

To establish a structure for building and sustaining
EBP, a majority of the governance committees were
charged with specific responsibilities. These gover-
nance committees include committee chairs, SOC,
standards of practice, nursing clinical quality
improvement, staff education, and research. Com-
mittee chairs consist of the chairs and cochairs for
each of the governance committees. Committee
chairs drafted EBP committee goals that were
aligned with the purpose of each committee. Each
committee then reviewed and revised or supported
these goals. In addition, the purpose and functions
of each committee were reviewed in light of
the EBP initiative. During implementation, each

Table 1. Strategic Plan to Infuse The Johns Hopkins Nursing Evidence-Based Practice
(EBP) Model

Objectives Responsibility

Build local experts through the following Central committees

1. Each functional unit will complete 1 EBP project using The Johns Hopkins
Nursing EBP Model and Guidelines.

2. Central committee members (research, standard of care, education, and nursing
clinical quality improvement) will collaborate on choosing the practice question,
leading the EBP process, recommending the practice changes if indicated,
assuring that the implementation occurs, and evaluating the outcome of the project.

3. Functional units will develop a practice question and identify EBP team members
in consultation with central committee representatives.

4. Functional units will create a plan for staff education, format selecting from the
options listed below.

Develop EBP education programs EBP core members

Target: trainers
1. Small group rapid cycle or 1-day training
2. Train the trainer competencies (health stream)

Target: staff
Mandatory health stream training is dependent on job description. EBP core members with

committee approval1. Health stream
Module 1: Introduction (history, definitions, model, and practice question)
Module 2: Searching evidence (defining terms, sources, and technique)
Module 3: Evaluating the evidence (rating, summarizing, and recommending
practice changes)
Module 4: Implementing practice changes

Optional training if desired
2. Health stream plus day practicum
3. One-day workshop by core mentors and trainers scheduled by functional unit

Develop Web-based resources for all nursing staff to access EBP core members

1. Model and guidelines (manual)
2. Tools (practice question, rating scales, critique summaries, project management

guide, and evaluation)
Modify job description criteria to include behavioral outcomes for EBP Standards of practice

1. Nurse clinician IVobjectives related to module 1
2. Nurse clinician IIM and EVobjectives related to modules 1-3
3. Nurse clinician IIIVparticipation in 1 EBP project per year (modules 1-4)

Define origin of potential question generation EBP core members

Problem prone/high-risk clinical processes or diagnosis, evidence to support the
practice challenged, or high variations in practice or outcomes.

Build EBP competencies Nursing administration/
departments1. Require module 1 for all current registered nurses (RNs) in 2006.

2. Require module 1 for all newly hired RNs within the first year of employment.

JONA Vol. 37, No. 12 December 2007 553

committee in the governance structure had respon-
sibility for a specific goal (Figure 1). The SOC
committee became responsible for reporting prog-
ress and monitoring outcomes of the EBP initia-
tives within each department. This structure was
important because it infused the responsibility for
EBP across the professional governance commit-
tees, making nurse leaders on the committees
accountable for growing and sustaining the EBP
program. To continue to enhance EBP expertise
and engagement, each department is completing at
least 1 project over a 15-month period.

Developing an EBP Skill Set

One of the most important steps in the plan was to
develop EBP experts that would act as future
mentors. These individuals were to be the primary
champions and facilitators of EBP. They were
members of the governance committees; thus,
incorporating EBP goals into responsibilities as a
committee member was well aligned with moving
the strategic initiative ahead.19

In addition, nurse schedules needed to accom-
modate time away from clinical responsibilities for
initial training and then later to complete the EBP
process. The buy-in from nursing leadership was
essential to support nurse scheduling to meet the
training requirements, provide the needed encour-
agement, and assure that the EBP projects were
focused on an important area for which practice
recommendations were needed.

Development of Material Resources

A number of resources needed to be established to
foster the growth and development of the program.
These resources included the availability of the

JHN EBP model, process, guidelines, and tools in
written and electronic formats. It was also impor-
tant to assure that library, database, and Web
resources were accessible to each nurse.

Training and mentorship were offered in each
department through the committee member men-
tors who had completed initial training. The authors
(core EBP group) were also available for committee
members and teams. Because there is not one
strategy that is always successful, the team planned
multiple strategies for training and education.8 Our
goal to develop EBP skills and competencies
required that we develop a training and education
plan, using several approaches to meet the needs of
the nurses and organization through multimethod
education, demonstration, mentorship, and fellow-
ship. Examples of strategies included rapid cycle
training, a 1-and 2-day seminar approach, multi-
disciplinary groups, completion of projects within
the committee structure, and committee members
mentoring teams in their departments.

In addition to these educational approaches, a
fellowship in EBP was developed and budgeted
through the department of nursing administration.
Two fellowships were awarded through a compet-
itive process that provided salary support for 20
hours per week for 3 months. This opportunity
provided the time needed for the fellows to develop
advanced EBP skills to prepare them to lead EBP
initiatives at the unit, functional unit, and hospital
levels. The first fellow focused on delirium screen-
ing and nursing interventions to decrease the
intensity, frequency, and duration of delirium. Re-
sults of her project were used to provide education
to unit nurses. She also completed her first pub-
lication. The team recommended that the next
fellowship be assigned by the SOC committee to
better align the fellows work with the needs of

Figure 1. The shared governance role in the implementation of evidence-based practice (EBP).

554 JONA Vol. 37, No. 12 December 2007

the organization. A protocol was selected in the
ophthalmology department, with the second fellow
facilitating and supporting their EBP process.

An additional resource developed was EBP
assistants who were available on an as-needed basis
for unit projects. These assistants were undergrad-
uate nursing students from local universities. Exam-
ples of the types of support they provided include
running literature searches, retrieving requested
articles, disseminating the teams evidence summa-
ries, and documenting EBP team meetings. The
salary for these assistants was initially supported
through a small grant from the Maryland Health
Services Cost Review Commission. After a favor-
able evaluation of this resource at the end of the
funding period, EBP assistants were included in
subsequent nursing administration budgets.

Setting Expectations

To incorporate EBP as an expectation of nursing
practice, nursing staff job descriptions were revised
after significant input from the governance com-
mittees, staff, and managers. An example of a
revision is provided in Figure 2. It was important to
construct language that was broad enough to allow
different units to apply the standard to fit their
needs. All indirect care positions are now under
review for incorporating EBP expectations.

A basic Web EBP course was developed in 2005
and implemented as a required competency for
RNs in 2006 to promote understanding of the EBP
program, goal, and resources. The basic compe-
tency education will move from yearly competency
to the nurse orientation curriculum for 2007. Three
additional modules are in development to address
educational needs beyond basic competencies.

Collaborative Strategies: Introduction of
the Model to the School of Nursing

Since the early 1990s, research utilization has been
a major focus in the undergraduate research
courses at Johns Hopkins University School of
Nursing (JHUSON). As the focus changed from
research utilization to EBP and the JHN EBP team
began presenting their model and resources, part of
the implementation plan was to infuse EBP into the
JHUSON. In fall of 2004, a pilot was conducted
with 1 section of the undergraduate research class.
The class used the JHN EBP tools and worked on a
project from a problem identified by nurses at The
Johns Hopkins Hospital. The requirement for an
undergraduate EBP project was revised with full
implementation using the JHN EBP model in the
spring semester of 2005.

At the same time, the masters program curric-
ulum was being revised. Revisions were driven by

Figure 2. Job descriptions revisions to incorporate evidence-based practice (EBP) into standard: maintains awareness of
scientific basis for nursing practice.

JONA Vol. 37, No. 12 December 2007 555

the belief that the research course should prepare
advanced practice nurses to translate evidence into
the best practices. A new course was developed:
Application of Research to Practice. The skills
demonstrated are essential for the EBP organiza-
tional leader. Two outcomes of this course include
(1) conducting a team EBP project and (2) demon-
strating evidence critique and rating competencies
in an individual state of the sciences paper. The
focus of these assignments can be clinical, admin-
istrative, or educational nursing problems.

Incorporating these changes into the JHUSON
curriculum also required faculty training in the
conceptual underpinnings of the model as well as
the EBP process and available tools. Three members
of the team presented a faculty training seminar,
covering the model, tools, and process. A mock
critique and rating session provided the faculty with
a hands_on experience with the tools and process.

Lessons Learned

The EBP implementation and infusion described in
this article occurred between 2004 and 2006. The
team learned a number of lessons, which include
the importance of leadership support to foster the
strategic plan, the need for flexibility in training

approaches to meet the requirements of the staff,
the necessity of strategic resource planning, the
essential role of mentors, and the need to have a
model and tools available. Seeking synergistic
opportunities to collaborate with academic institu-
tions and students provides a win-win outcome.20

Model and Tool Revisions

We have used the model and guidelines previously
published21 in multiple projects within and outside
the organization. Based on this experience, we have
kept the PET (practice question, evidence, transla-
tion) process in place but have made some modifi-
cations to the tools used for the EBP project (Figure 3)
and further refined the graphic for the conceptual
model (Figure 4). Within the JHN EBP model, EBP
is a problem-solving approach to making clinical,
educational, and administrative decisions that
combines the best available scientific evidence with
the best available practical evidence. The process
takes internal and external influences on practice
into consideration and requires the nurse to use
critical thinking when applying the evidence.17

Future Directions

The JHN EBP has evolved into a mature phase of
development. To move to the next stage, we need
to develop and mentor additional EBP experts,
expand the use of the model and tools, and
continue to make revisions based on our experi-
ences. We have planned additional training for staff
and mentors, continued fellowships, and added a
seminar on publication to help nurses publish the
results their EBP projects. A book which includes
the JHN EBP model and tools is in press.22

Figure 3. Evidence-based practice tools.

Figure 4. The Johns Hopkins Nursing Evidence-based Practice Conceptual Model.

556 JONA Vol. 37, No. 12 December 2007

We continue to support the strategic plan for
our organization to facilitate the infusion of EBP
into every component of nursing practice, provid-
ing leadership, mentorship, and resources. The

plan must be flexible and iterative to incorporate
lessons learned, to adapt the process to meet the
needs of the nurses, and to continue to develop
opportunities to engage and build skills for nurses.

References

1. American Nurses Association. Scope and Standards for
Nurse Administrators. 2nd ed. Washington, DC: Nurse-
books; 2004.

2. American Nurses Association. Nursing: Scope and Stan-

dards of Practice. Washington, DC: American Nurses
Association; 2004.

3. Committee on the Health Professions Education Summit

Board on Health Care Services. In: Greiner AC, Knebel E,

eds. Health Professions Education: A Bridge to Quality.
Washington, DC: The National Academies Press; 2003.

4. American Nurses Credentialing Center. Magnet Recognition
Program. Silver Spring, MD: American Nurses Credential-
ing Center; 2005.

5. Newhouse RP. Examining the support for evidence-based

nursing practice. J Nurs Adm. 2006;36(7-8):337-340.
6. Scott-Findlay S, Golden-Biddle K. Understanding how

organizational culture shapes research use. J Nurs Adm.
2005;35(7-8):359-365.

7. Stetler CB. Role of the organization in translating research

into evidence-based practice. Outcomes Manag. 2003;7(3):
97-103.

8. NHS Centre for Reviews and Dissemination, University of

York. Effective Health Care: Getting Evidence Into Practice.

The Royal Society of Medicine Press Limited. 1999;5(1).
http://www.york.ac.uk/inst/crd/ehc51.pdf. Accessed October

17, 2007.

9. Fineout-Overholt E, Levin RF, Melnyk BM. Strategies for
advancing evidence-based practice in clinical settings. J N Y
State Nurses Assoc. 2004-2005;35(2):28-32.

10. Fineout-Overholt E, Melnyk BM. Building a culture of best

practice. Nurse Leader. 2005;3(6):26-30.
11. Thurston NE, King KM. Implementing evidence-based

practice: walking the talk. Appl Nurs Res. 2004;17(4):239-247.

12. Rosswurm MA, Larrabee JH. A model for change to

evidence-based practice. Image J Nurs Scholarsh. 1999;
31(4):317-322.

13. Kavanagh D, Connolly P, Cohen J. Promoting evidence-

based practice: implementing the American Stroke Associa-
tions Acute Stroke Program. J Nurs Care Qual. 2006;(21):
135-142.

14. Dickinson D, Duffy A, Champion S. Research in brief.

J Psychiatr Ment Health Nurs. 2004;11(1):117-119.
15. Mohide EA, Coker E. Toward clinical scholarship: promot-

ing evidence-based practice in the clinical setting. J Prof
Nurs. 2005;21(6):372-379.

16. Newhouse RP. Creating infrastructure supportive of evidence-
based nursing practice: leadership strategies. Worldviews
Evid Based Nurs. 2007;4(1):21-29.

17. Newhouse R, Dearholt S, Poe S, Pugh LC, White K. The
Johns Hopkins Nursing Evidence-Based Practice Model.
Baltimore, MD: Johns Hopkins University School of Nurs-

ing, The Johns Hopkins Hospital; 2005.

18. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O.
Diffusion of innovations in service organizations: systematic

review and recommendations. Milbank Q. 2004;82(4):581-629.
19. Dearholt S, White K, Newhouse RP, Pugh LC, Poe S. Making

the vision reality: educational strategies to develop evidence-
based practice mentors. J Nurses Staff Dev. In press.

20. Newhouse RP. Collaborative synergy: practice and academic

partnerships in evidence-based practice. J Nurs Adm. In press.
21. Newhouse RP, Dearholt S, Poe S, Pugh LC, White KM.

Evidence based practice: a practical approach to implemen-

tation. J Nurs Adm. 2005;35(1):35-40.
22. Newhouse RP, Dearholt S, Poe S, Pugh LC, White K. Johns

Hopkins Nursing Evidence-based Practical Model and Guide-

lines. Sigma Theta Tau International: Indianapolis, IN.

JONA Vol. 37, No. 12 December 2007 557 LWW/NAQ NAQ200184 March 1, 2012 23:19

Nurs Admin Q
Vol. 36, No. 2, pp. 127135
Copyright c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Achieving a High-Reliability
Organization Through
Implementation of the ARCC
Model for Systemwide
Sustainability of
Evidence-Based Practice

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
Navys 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 ([emailprotected]).

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

127

LWW/NAQ NAQ200184 March 1, 2012 23:19

128 NURSING ADMINISTRATION QUARTERLY/APRILJUNE 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 physicians 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 dir

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