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52/11 Assgn

NOTE FROM PROF

This week, you will be completing your final assignment. This is a 5-6 slide narrated/speaker notes PowerPoint presentation. In the presentation you will incorporate any feedback from your week 9 PowerPoint and reduce the overall presentation to 5 slides. Some additional points:

You will use your PowerPoint from module 5 as the basis
This presentation is a total of 5-6 slides
You will focus on the dissemination strategy for your practice change
Be sure to include a slide which identifies your topic, the issue, and the rationale for implementing this practice change
You will not need to include the lessons learned section
This assignment requires that you narrate the presentation, however there are 2 options you can choose from:
Narrate each slide

Include detailed speaker notes for each slide

Keep in mind that when creating a presentation, each slide should include clear, and concise information. The majority of the detail will be in either the narration or the speaker notes. When you narrate/speaker notes for your presentation, you should be providing additional information than is on the slide. You should not read directly from the slide.

PROJECT

The dissemination of EBP results serves multiple important roles. Sharing results makes the case for your decisions. It also adds to the body of knowledge, which creates opportunities for future practitioners. By presenting results, you also become an advocate for EBP, creating a culture within your organization or beyond that informs, educates, and promotes the effective use of EBP.

To Prepare:

Review the final PowerPoint presentation you submitted in Module 5, and make any necessary changes based on the feedback you have received and on lessons you have learned throughout the course.
Consider the best method of disseminating the results of your presentation to an audience.

To Complete:

Create a 5-minute, 5- to 6-slide narrated PowerPoint presentation of your Evidence-Based Project.

Be sure to incorporate any feedback or changes from your presentation submission in Module 5.
Explain how you would disseminate the results of your project to an audience. Provide a rationale for why you selected this dissemination strategy.

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Implementing an Evidence-Based Practice Change
Beginning the transformation from an idea to reality.

This is the ninth article in a series from the Arizona State University College of Nursing and Health Innovation’s Cen-
ter for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to
the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise
and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture,
the highest quality of care and best patient outcomes can be achieved.

The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one
step at a time. Articles will appear every other month to allow you time to incorporate information as you work to –
ward implementing EBP at your institution. Also, we’ve scheduled “Chat with the Authors” calls every few months to
provide a direct line to the experts to help you resolve questions. Details about how to participate in the next call will
be published with May’s Evidence-Based Practice, Step by Step.

In January’s evidence-based prac tice (EBP) article, Rebe -cca R., our hypothetical staff
nurse, Carlos A., her hospital’s
ex pert EBP mentor, and Chen
M., Rebecca’s nurse colleague,
began to develop their plan for
implementing a rapid response
team (RRT) at their institution.
They clearly identified the pur-
pose of their RRT project, the
key stakeholders, and the vari-
ous outcomes to be measured,
and they learned their internal
re view board’s requirements for
re viewing their pro posal. To de-
termine their next steps, the team
consults their EBP Implementa-
tion Plan (see Figure 1 in “Fol-
lowing the Evidence: Plan ning
for Sustainable Change,” Jan –
uary). They’ll be working on
items in checkpoints six and

seven: specif ically, engaging the
stakeholders, getting administra-
tive support, and preparing for
and conducting the stakeholder
kick-off meeting.

ENGAGING THE STAKEHOLDERS
Carlos, Rebecca, and Chen reach
out to the key stakeholders to tell
them about the RRT project by
meeting with them in their offices
or calling them on the phone. Car –
los leads the team through a dis-
cussion of strategies to promote
success in this critical step in the
implementation process (see Strat
egies to Engage Stakeholders). One
of the strategies, connect in a col
laborative way, seems espe cially
applicable to this project. Each
team member is able to meet with
a stakeholder in person, fill them
in on the RRT project, describe
the purpose of an RRT, discuss
their role in the project, and an –
swer any questions. They also tell
each stakeholder about the initial
project meeting to be held in a few
weeks.

In anticipation of the stake-
holder kick-off meeting, Carlos
and the team discuss the fun –
damen tals of preparing for an

im portant meeting, such as how
to set up an agenda, draft key doc-
uments, and conduct the meet –
ing. They begin to discuss a time
and date for the meeting. Carlos
suggests that Rebecca and Chen
meet with their nurse manager
to up date her on the project’s
pro gress and request her help in
sched uling the meeting.

SECURING ADMINISTRATIVE SUPPORT
After Rebecca updates her man-
ager, Pat M., on the RRT pro ject,
Pat says she’s impressed by the
team’s work to date and of fers
to help them move the project
forward. She suggests that, since
they’ve already invited the stake-
holders to the upcoming meet ing,
they use e-mail to communicate
the meeting’s time, date, and
place. As they draft this e-mail
together, Pat shares the follow –
ing tips to im prove its effective-
ness:
• communicate the essence and

importance of the e-mail in the
subject line

• write an e-mail that’s engaging,
but brief and to the point

• introduce yourself
• explain the project

54 AJN ▼ March 2011 ▼ Vol. 111, No. 3 ajnonline.com

Strategies to Engage Stakeholders
• Spend time and effort building trust.
• Understand stakeholders’ interests.
• Solicit input from stakeholders.
• Connect in a collaborative way.
• Promote active engagement in establishing

metrics and outcomes to be measured.

By Lynn Gallagher-Ford, MSN, RN, NE-BC, Ellen
Fineout-Overholt, PhD, RN, FNAP, FAAN, Bernadette

Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP,
FAAN, and Susan B. Stillwell, DNP, RN, CNE

• welcome the recipients to the
project and/or team and invite
them to the meeting

• explain why their attendance
is critical

• request that they read certain
materials prior to the meeting
(and attach those documents
to the e-mail)

• let them know whom to con-
tact with questions

• request that they RSVP
• thank them for their partici-

pation
Before they send the e-mail (see
Sample Email to RRT and Stake
holders), the team wants to make
sure they don’t miss anyone, so
they review and include all of the
RRT members and stake holders.
They realize that it’s im portant to
invite the manager of each of the
stakeholders and disciplines rep-
resented on the RRT and ask

them to also bring a staff represen-
tative to the meeting. In addition,
they copy the administrative di rec –
tors of the stakeholder depart-
ments on the e-mail to en sure that
they’re fully aware of the project.

PREPARING FOR THE KICK-OFF
MEETING
The group determines that the
draft documents they’ll need to
prepare for the stakeholder kick-
off meeting are:
• an agenda for the meeting
• the RRT protocol
• an outcomes measurement plan
• an education plan
• an implementation timeline
• a projected budget
To expedite completion of the doc-
uments, the team divides them up
among themselves. Chen volun-
teers to draft the RRT protocol
and outcomes measurement plan.

Carlos assures her that he’ll guide
her through each step. Rebecca
decides to partner with her unit ed-
ucator to draft the education plan.
Carlos agrees to take the lead in
drafting the meeting agenda, im –
plementation timeline, and pro-
jected budget, but says that since
this is a great learning opportu-
nity, he wants Rebecca and Chen
to be part of the drafting process.

Drafting documents. Carlos
tells the team that the purpose of
a draft is to initiate discussion and
give the stakeholders an oppor tu –
nity to have input into the final
prod uct. All feedback is a positive
sign of the stakeholders’ involve-
ment, he says, and shouldn’t
be per ceived as criticism. Carlos
also offers to look for any tem-
plates from other EBP projects
that may be helpful in drafting
the documents. He tells Rebecca

ajn@wolterskluwer.com AJN ▼ March 2011 ▼ Vol. 111, No. 3 55

Sample E-mail to RRT and Stakeholders
To: ICU Nurse Manager, 3 North Nurse Manager, Respiratory Therapy Director, Medical Director of ICU, Director of
Acute Care NP Hospitalists, Director of Spirituality Department

cc: EBP Council Chair, VP Nursing, VP Medical Affairs, ICU Nursing Director, Medical–Surgical Nursing Director,
Finance Department Director, Communications Department Director, Risk Management Director, Education Department
Director, HIMS (Medical Records) Director, Quality/Performance Improvement Director, Clinical Informatics Director,
Pharmacy Director

Subject: Invitation to the Rapid Response Project Stakeholder Kick- off Meeting

Good afternoon. I would like to introduce myself. My name is Rebecca R. I am a staff nurse III on the 3 North medical–
surgical unit. You have either spoken with me or with one of my colleagues, Carlos A. or Chen M., about an important
evidence-based initiative that will help improve the quality of care for our patients. The increasing patient acuity on our
unit and throughout the hospital, and the frequent need for patients to be transferred to the ICU, prompted us to ask
important questions about patient outcomes. For the past few months, Carlos, Chen, and I have been investigating how
our hospital can reduce the number of codes, particularly outside the ICU. We have conducted a thorough search for
and appraisal of current available evidence, which we would like to share with you.

Our team and our managers would like to invite you to participate in a kick-off meeting to discuss an exciting
evidence-based initiative to improve the quality of patient care in our hospital. The meeting will be held on March 1,
2011, at 10 am in the Innovation Conference Room on the 2nd floor. It is very important that you attend this meeting
as you have been identified as a critical participant in this project. We need your input and support as we move for-
ward. So please plan to attend the meeting or send a representative. To ensure that we have sufficient materials for the
meeting, please RSVP to Mary J., unit secretary on 3 North.

I want to thank you in advance for your help with and support of this project. I look forward to seeing you at the
meeting. If you have any questions, please feel free to contact me or any of the RRT project team members.

Rebecca R. and the RRT Project Team

56 AJN ▼ March 2011 ▼ Vol. 111, No. 3 ajnonline.com

RRT Protocol Draft for Review
Current evidence supports the effectiveness of an RRT in decreasing adverse events in patients who exhibit specific clinical parameters.
Evidence-based recommendations include that RRTs should be available on general units of hospitals, 24 hours a day and seven days
a week, staffed by intensive care clinicians, and activated based on established clinical criteria. The RRT serves a dual purpose of pro-
viding both early intervention care to at-risk patients and education in recognizing and managing these patients to clin ical staff.

The RRT is available to respond to and assist bedside staff in caring for patients who develop signs or symptoms of clinical deterio-
ration.

RRT Members
RRT members are all ACLS certified. They include:
Team Leader: Acute Care NP Hospitalist (credentialed in advanced procedures)
Team Members: ICU RN

Respiratory Therapist (trained in intubation)
Physician Intensivist (ICU MD on call and available to the RRT)
Hospital Chaplain

Initiation of RRT Consult
An RRT consult can be initiated by any bedside clinician. Consults should be initiated based on the following patient status criteria.

RRT Consult Initiation Criteria

Pulmonary

Ventilation: Color change (pale, dusky, gray, or blue)

Respiratory distress: RR < 10 or > 30 breaths/min, or
Unexplained dyspnea, or
New-onset difficulty breathing, or
Shortness of breath

Cardiovascular

Tachycardia: Unexplained > 130 beats/min for 15 mins

Bradycardia: Unexplained < 50 beats/min for 15 mins

Blood pressure: Unexplained SBP < 90 or > 200 mmHg

Chest pain: Complaint of nontraumatic chest pain

Pulse oximetry: < 92% SpO2 Perfusion: UOP < 50 cc/4 hr

Neurologic

Seizures: Initial, repeated, or prolonged

Change in mental status: Sudden decrease in LOC with normal blood sugar
Unexplained agitation for > 10 min
New- onset limb weakness or smile droop

Sepsis

Clinical indicators of sepsis: Temperature > 38ºC

HR > 90 beats/min

RR > 20 breaths/min

WBC > 12,000, < 4,000

Nurse’s concern about overall deterioration in patient’s condition without any of the above criteria.

Scope of the RRT
The RRT can be expected to perform any/all of the following interventions:
Nasopharyngeal/oropharyngeal suctioning
Oxygen therapy

ajn@wolterskluwer.com AJN ▼ March 2011 ▼ Vol. 111, No. 3 57

Initiation of CPAP
Initiation of nebulized medications
Intravenous fluid bolus(es)
Intravenous fluid bolus(es) with medication
CPR

The RRT can be expected to perform any/all of the following invasive procedures:
Endotracheal intubation
Intravenous line insertion
Intraosseous line insertion
Arterial line insertion
Central line insertion

RRT Consult Procedure
1. Assess patient relative to the above criteria.
2. If any of the above criteria are identified, initiate the RRT consult by calling 5-5555. The operator will request the caller’s location,

the patient’s name, the patient’s location, and the reason for RRT activation. This call will generate both pages to the RRT members
and an overhead announcement.

3. The RRT will arrive within five minutes (or less) of the call.
4. Be prepared to provide the RRT with appropriate information about the patient using the SBAR communication method. (See stan-

dardized communication protocol no. 7.)
5. While awaiting the arrival of the RRT, consider initiating any/all of the following actions:

• Call for a colleague to help you
• Set up oxygen apparatus
• Set up suction apparatus
• Call for the code cart to be brought to the area
• Communicate with the patient’s family (if present); tell them what you’re doing and why and that someone will be here shortly

to help them
• Obtain proper documentation tools to be used during the RRT consult

RRT Arrival
When the RRT arrives:
1. Provide information as indicated above.
2. Participate in the care of your patient and remain with the patient and the RRT.
3. Assist the RRT as needed.
4. Document activities, interventions performed, and patient responses to interventions.
5. Work with the chaplain to ensure that the patient’s family is informed of the situation at intervals.
6. Assist in arranging for transfer of the patient to a higher level of care if indicated.
7. Provide a detailed report to the nurse accepting the patient on the receiving unit, utilizing the SBAR communication method.

ACLS = advanced cardiac life support; cc = cubic centimeters; CPAP = continuous positive airway pressure; CPR = cardiopulmonary resusci-
tation; hr = hours; HR = heart rate; ICU = intensive care unit; LOC = level of consciousness; MD = medical doctor; min = minute; mmHg =
millimeters of mercury; NP = nurse practitioner; RN = registered nurse; RR = respiratory rate; RRT = rapid response team; SBAR = situation-
background-assessment-recommendation; SBP = systolic blood pressure; SpO2 = arterial oxygen saturation; UOP = urine output; WBC = white
blood count.

REFERENCES
1. Choo CL, et al. Rapid response team: a proactive strategy in managing haemodynamically unstable adult patients in the acute care hospitals.

Singapore Nursing Journal 2009;36(4);17-22.
2. Winters BD, et al. Rapid response systems: a systematic review. Crit Care Med 2007;35(5):1238-43.
3. Hillman K, et al. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005;365(9477):2091-7.
4. Sharek PJ, et al. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. JAMA 2007;

298(19):2267-74.
5. Mailey J, et al. Reducing hospital standardized mortality rate with early interventions. J Trauma Nurs 2006;13(4):178-82.
6. Dacey MJ, et al. The effect of a rapid response team on major clinical outcome measures in a community hospital. Crit Care Med 2007;35(9):

2076-82.
7. Benson L, et al. Using an advanced practice nursing model for a rapid response team. Jt Comm J Qual Patient Saf 2008;34(12):743-7.
8. Hatler C, et al. Implementing a rapid response team to decrease emergencies. Medsurg Nurs 2009;18(2):84-90, 126.
9. Bader MK, et al. Rescue me: saving the vulnerable non-ICU patient population. Jt Comm J Qual Patient Saf 2009;35(4):199-205.
10. DeVita MA, et al. Use of medical emergency team responses to reduce cardiopulmonary arrests. Qual Saf Health Care 2004;13(4):251-4.

58 AJN ▼ March 2011 ▼ Vol. 111, No. 3 ajnonline.com

and Chen that he’s confident they’ll
do a great job and shares his ex –
cite ment at how the team has pro-
gressed in planning an EBP practice
change.

RRT protocol. Chen starts to
draft the RRT protocol using one
of the hospital’s protocols as a
tem plate for the format, as well
as definitions and examples of
protocols, policies, and proce-
dures from other organizations
and the literature. She returns to
the articles from the team’s origi-
nal literature search (see “Critical
Appraisal of the Evidence: Part I,”
July 2010) to see if there is infor-
mation, previously appraised, that
will be helpful in this current step
in the process. She recalls that the
team had set aside some articles
be cause they didn’t directly an –
swer the PICOT question about
whether to implement an RRT,
but they did have valuable infor-
mation on how to implement an
RRT. In reviewing these articles,
Chen selects one that’s a review
of the literature, though not a
sys tematic review, that includes

many examples of RRT member-
ship rosters and protocols used
in other hospitals, and which
will be help ful in drafting her
RRT protocol document.1 Chen
includes this ex pert opinion ar-
ticle be cause the informa tion it
contains is consistent with the
higher-level evidence already
being used in the project. Using
both higher and lower levels of
evidence, when appropriate, al –
lows the team to use the best infor –
mation available in formulating
their RRT protocol.

As she writes, Chen discovers
that their hospital’s protocols and
other practice documents don’t in –
clude a section on supporting evi-
dence. Knowing that evidence is
critically important to the RRT
pro tocol, she discusses this with the
clinical practice council represen-
tative from her unit who advises
her to add the section to her draft
document. He promises to present
this issue at the next coun cil meet –
ing and obtain the council’s ap –
proval to add an evidence section
to all future practice documents.

Chen reviews the finished product
before she submits it for the team’s
review (see RRT Protocol Draft
for Review1-10).

Outcomes measurement plan.
Based on the appraised evidence
and the many discussions Rebe –
cca and Chen have had about it,
Chen drafts a document that lists
the outcomes the team will mea-
sure to demonstrate the success of
their project, where they’ll ob tain
this information, and who will
gather it (see Table 1). In draf ting
this plan, Chen realizes that they
don’t have all the information
they need, and she’s concerned
that they’re not ready to move
for ward with the stakeholder
kick- off meeting. But when Chen
calls Carlos and shares her con-
cern, Car los reminds her that the
document is a draft and that the
re quired information will be ad –
dressed at the meeting.

Education plan. Rebecca
reaches out to Susan B., the clin ical
educator on her unit, and requests
her help in drafting the education
plan. Susan tells Rebe cca how much

Table 1. Plan for Measuring RRT Success (Draft for Discussion)

Outcome Measurement Source/Owner

CRO • Codes outside of the ICU • EMR

Mortality rates:
HMR and NIM

• Hospital mortality rates by unit • Discuss at meeting

UICUA • ICU admissions
 planned
 unplanned

• EMR; ICU admissions database; check
box needed to indicate planned and
unplanned

Return on RRT investment
(cost of RRT compared with savings
due to RRT)

1. Cost of RRT
• Personnel
• Supplies

2. Savings due to RRT
• Cost of UICUA
• Number of UICUA prevented

• RRT personnel cost/hour

• UICUA cost/day
• LOS for average UICUA
• Number of UICUA prevented

• Billing data
• RRT response time and end time as re

corded on the

RRT data documentation tool

• Billing data
• Disposition of RRT call as recorded on the

RRT data documentation tool

CRO = code rates outside the ICU; EMR = electronic medical record; HMR = hospital-wide mortality rates; ICU = intensive care unit;
LOS = length of stay; NIM = non-ICU mortality; RRT = rapid response team; UICUA = unplanned ICU admissions.

ajn@wolterskluwer.com AJN ▼ March 2011 ▼ Vol. 111, No. 3 59

she enjoys the op portunity to work
collaboratively with staff nurses on
education pro jects and how happy
she is to see an EBP project being
implemented. Rebecca shares her
RRT project folder (containing all
the informa tion relative to the pro-
ject) with Susan, focusing on the
education about the project she
thinks the staff will need. Susan
commends the team for its efforts,
as a good deal of the necessary
work is al ready done. She asks
Rebecca to clarify both the ulti-
mate goal of the project and what’s
most im por tant to the team about
its rollout on the unit. Rebecca
thoughtfully responds that the
ultimate goal is to ensure that
patients re ceive the best care possi-
ble. What’s most im portant about
its rollout is that the staff sees the
value of an RRT to the patients
and its positive impact on their
own workload. She adds that it’s

im portant to her that the project
be conducted in a way that feels
pos itive to the staff as they work
to ward sustain able changes in
their practices.

Susan and Rebecca discuss
which clinicians will need edu –
cation on the RRT. They plan to
use a variety of mechanisms, in –
clud ing in-services, e-mails, news-
letters, and flyers. From their
conversation, Susan agrees to
draft an education plan using a
template she developed for this
purpose. The template prompts
her to put in key elements for
planning an education program:
learner objectives, key content,
methodology, faculty, materials,
time frame, and room location.
Susan fills the template with in-
formation Rebecca has given her,
adding information she knows
already from her expe rience as
an educator. When Rebecca and

Susan meet to re view the plan,
Rebecca is amazed to see how
their earlier conversation has
been transformed into a com-
prehensive document (see the
Education Plan for RRT Imple
mentation at http://links.lww.
com/AJN/A19).

Agenda and timeline. The
team meets to draft the meeting
agenda, implementation timeline,
and budget. Carlos explains the
purposes of a meeting agenda: to
serve as a guide for the participants
and to promote productivity and
efficiency. They draft an agenda
that includes the key issues to be
shared with the stakeholders as
well as time for questions, feed-
back, and discussion (see the
Rapid Response Team Kickoff
Meeting Agenda at http://links.
lww.com/AJN/A20).

Carlos describes how the time-
line creates a structure to guide

Table 3. RRT Project Budget Draft (Draft for Discussion)

Annual Costs

Item Projected Cost/Unit No. Units
Needed

Cost/Year Cost Center Approval
Needed

Notes:

RRT pagers $30/month 8/month $2,880 Administration VP Nursing

Data
collection

RRT leader,
$45/hour

1 hour/month $540 Hospitalist VP Medical
Affairs

Data entry Administrative
assistant,
$15/hour

1 hour/month $180 Nursing
administration

Medical–
surgical
director

Data
analysis

Data manager,
$21/hour

1 hour/month $252 Quality Quality
manager

First Year Start-Up Costs

Education
prep

Advanced practice
nurse, $45/hour

2 Project leaders,
$30/hour

Nurse manager,
$40/hour

6 hours

6 hours each

2 hours

$270

$360

$80

Total = $710

3 North Nursing 3 North Nurse
manager

Unit educators
will schedule their
time to provide
the in-services.
No additional
cost.

Education
delivery

80 Staff members,
$30/hour (average
rate)

1/2 hour each $1,200 Departmental
education
budgets

Department
managers

This is the cost for
the pilot unit only.

http://links.lww.com/AJN/A19

http://links.lww.com/AJN/A20

60 AJN ▼ March 2011 ▼ Vol. 111, No. 3 ajnonline.com

the project (see Table 2 at http://
links.lww.com/AJN/A21). The
team further discusses how it can
maintain the project’s momen-
tum by keeping it moving for-
ward while at the same time
accommodate unexpected delays
or resistance. There are a few
items on the timeline that Carlos
thinks may be underestimated―
for example, the team may need
more than a month to meet with
other departments because of al-
ready heavily scheduled calendars―
but he decides to let it stand as
drafted, knowing that it’s a guide
and can be adjusted as the need
arises.

Budget. Carlos discusses the
budget with the team. Rebecca
shares a list of what she thinks
they’ll need for the project and the
team decides to put this informa-
tion into a table format so they can
more easily identify any missing
information. Before they construct
the table, they walk through an
imaginary RRT call to be sure
they’ve thought of all the budget
implications of the project. They
realize they didn’t include the cost
of each employee attending an
education session, so they add
that figure to the budget. They
also realize that they’re missing
hourly pay rates for the different
types of employees involved. Car-
los tells Rebecca that he’ll work
with the Human Resources De-
partment to obtain this informa-
tion before the meeting so they
can complete the budget (see
Table 3).

REVIEWING THEIR WORK
The next time they meet, the EBP
team reviews the agenda for the
meeting and the documents they’ll

be presenting. The clerical person
on Rebecca and Chen’s floor (some-
times called the unit secretary)
has kept a record of who’s attend-
ing the meeting and the team is
pleased that most of the stake-
holders are coming. Carlos in-
forms the team that he received
notification that their internal re-
view board submission has been
approved. They’re excited to check
that step off on their EBP Imple-
mentation Plan.

Carlos suggests that they dis-
cuss the kick-off meeting in detail
and brainstorm how to prepare
for any negative responses to their
project that might occur. Rebecca

and Chen remark that they’ve
never considered that someone
might not like the idea of an RRT.
Carlos says he’s not surprised; of-
ten the passion that builds around
an EBP project and the hard work
put into it precludes taking time
to think about “why not.” The
team talks about the importance
of stopping occasionally during
any project to assess the environ-
ment and par ticipants, recogniz-
ing that people often have different
perspectives and that everyone
may not support a change. Carlos
reminds the team that people
may simply resist changing the
routine, and that this can lead to
the sabotage of a new idea. As
they explore this possible resis-
tance, Rebecca shares her concern
that with everyone in the hospital
so busy, adding something new
may be too stressful for some peo-
ple. Carlos tells Rebecca and Chen
that helping project participants
realize they’ll be doing the same
thing they’ve been doing, just in a
more efficient and effective way, is
generally successful in helping them

accept a new process. He reminds
them that many of the people on
the RRT are the same people who
currently take care of patients if
they code or are admitted to the
ICU; however, with the RRT pro-
tocol, they’ll be intervening ear-
lier to improve

patients’ outcomes.

The team feels confident that, if
needed, they can use this approach
at the kick-off meeting.

CONDUCTING THE KICK-OFF MEETING
Rebecca and Chen are both ner-
vous and excited about the meet-
ing. Carlos has made sure they’re
well prepared by helping them set
up the meeting room, computer,
PowerPoint presentation, and
handout packets containing the
agenda and draft documents. The
team is ready, and they’ve placed
themselves at the head of the ta –
ble so they can be visible and ac-
cessible. As the invitees arrive,
they welcome each one individu-
ally, thanking them for participat-
ing in this important meeting.
The team makes sure that the
meeting is guided by the agenda
and moves along through the
presentation of information to
thoughtful questions and a lively
discussion.

Join the EBP team next time as
they launch the RRT project and
tackle the real-world issues of
project implementation. ▼

Lynn GallagherFord is assistant direc
tor of the Center for the Advancement
of EvidenceBased Practice at Arizona
State University in Phoenix, where Ellen
FineoutOverholt is clinical pro fessor and
director, Susan B. Stillwell is associate di
rector, and Bernadette Mazurek Melnyk
is dean and distinguished foundation pro
fessor of nursing at the College of Nursing
and Health Innovation. Contact author:
Lynn GallagherFord, lynn.gallagherford@
asu.edu.

REFERENCE
1. Choo CL, et al. Rapid response team:

a proactive strategy in man aging
haemodynamically unstable adult
patients in the acute care hospitals.
Singapore Nursing Journal 2009;
36(4);17-22.

With the RRT protocol, staff will be
intervening earlier to improve

patients’ outcomes.

http://links.lww.com/AJN/A21

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 department’s
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, Master’s
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 (spoe@jhmi.edu).

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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

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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 fellow’s 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

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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 team’s 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 master’s 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

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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

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Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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 . 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-
tion’s 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

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Nurs Admin Q
Vol. 36, No. 2, pp.

127

–135
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
Navy’s 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 (Melnyk.15@osu.edu).

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/APRIL–JUNE 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 physician’s 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 direct care clinicians, patients, and family
members. Input from others is taken into con-
sideration in establishing care processes and
strategies to improve safety and quality.

The fifth key concept in an HRHO is re-
silience. In an HRHO, leaders and staff need
to be trained in how to respond when system
failures do occur. They must be prepared and
equipped with the right tools and resources

to be able to respond to at-risk situations and
prevent medical errors or sentinel events from
occurring.20

In an HRHO, effective teams are key to op-
timal functioning. Characteristics of effective
teams in HROs include (a) outstanding team
leadership, in which team members have a
clear vision and purpose and the roles of each
team member are clear; (b) backup behavior,
which is when team members are capable of
self-correcting behaviors and feedback is pro-
vided regularly; (c) mutual performance mon-
itoring, where team members understand and
monitor each other’s roles; (d) communica-
tion adaptability, in which communication is
clear, often, and enough; and (e) mutual trust,
in which each member of a team trusts each
other’s intentions.21

A CULTURE OF PATIENT SAFETY

Although a culture of patient safety is a ne-
cessity in an HRHO, it is often challenging to
define and measure a safe culture. In a com-
prehensive literature review whose purpose
was to organize the properties of a safety cul-
ture, Sammer and colleagues3 identified the
following as essential components: (a) lead-
ership, in which key leaders are aware that
the health care environment is one of risk
and seek to reduce risk by aligning the vi-
sion/mission, staff competencies, and fiscal
and human resources with frontline care; (b)
teamwork, which includes collaboration and
cooperation among leaders and staff mem-
bers; (c) evidence-based, in which practices
are based on the best evidence to improve
standardization and reduce variation; (d) com-
munication, in which the environment facili-
tates each member to speak up on behalf of a
patient; (e) learning, in which the health care
system learns from its mistakes and seeks to
continually improve its processes and perfor-
mance; (f) just, in which the culture is one
that sees errors as system failures rather than
individual failures; and (g) patient-centered,
in which the care in the health care system
is centered around the patients and family
members.

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130 NURSING ADMINISTRATION QUARTERLY/APRIL–JUNE 2012

MEASUREMENT OF PATIENT SAFETY

Data-driven decisions are an important part
of an HRHO; therefore, careful monitoring
of patient safety is essential. Scorecards can
be used to track patient safety outcomes. For
example, Pronovost and colleagues1 describe
the framework for a patient safety scorecard
in an HRO that includes the following: (a)
How often do we harm patients (measured
by the number of medical errors or sen-
tinel events, such as catheter-associated blood
stream infections)? (b) How often do we pro-
vide interventions that patients should receive
(eg, the proportion of patients who receive
evidence-based interventions)? (c) How often
do we learn from defects? (eg, the propor-
tion of months that each patient care area
learns from its mistakes and includes root-
cause analysis along with revised policies to
prevent future errors); (d) How well have we
created a culture of safety? (eg, the percent-
age of patient care areas in which 80% of the
staff report a positive safety and teamwork cli-
mate). The framework and concepts from an
HRO are helpful in developing HRHOs. How-
ever, it should be remembered that, although
concepts from HROs can be used to improve
processes and outcomes in health care sys-
tems, they are not meant to replace safety
and quality initiatives that are already be-
ing implemented and successful in improving
outcomes.

RECOMMENDATIONS FOR LEADERS TO
CREATE HIGH-RELIABILITY CULTURES

A variety of strategies can be implemented
by leaders to create HRHOs. The first strat-
egy is to conduct transdisciplinary team train-
ing in which all managers and staff are taught
about HROs and methods to achieve them.
The second strategy is deliberately designing
key care processes to reduce risk and en-
sure high-quality care. Third, it is important
that all members of the team understand its
key processes. Fourth, it is critical to error
proof the organization. The fifth strategy in-
volves process standardization (ie, uniformity

in how care is delivered to patients).21 Finally,
as part of building an HRHO, it is critical
to cultivate a culture of EBP in which there
is a never-ending spirit of inquiry within ev-
eryone in the organization regarding how to
improve the quality, safety, and efficiency of
care.

EVIDENCE IS KEY IN BOTH
HIGH-RELIABILITY ORGANIZATIONS
AND EVIDENCE-BASED PRACTICE
CULTURES

Careful tracking of data along with
outcomes monitoring of key system and
patient outcomes is critical in an HRHO.
Furthermore, external evidence from both
rigorous research and internal evidence (ie,
data that are generated from practice, pa-
tients, and outcomes management) is criti-
cal to formulating the best practices to im-
prove the quality and safety of care. In an
HRHO and an EBP culture, leaders engage
in evidence-based management and clinicians
engage in EBP. Evidence-based practice is a
problem-solving approach to the delivery of
care that integrates the best evidence from
well-designed studies with a clinician’s ex-
pertise, including clinical wisdom, reasoning,
patient history, physical data collection and
resource utilization, and a patient’s prefer-
ences and values to make decisions about the
type of care provided.22 The ultimate pur-
pose of EBP is to improve health care qual-
ity and patient outcomes and reduce hospital
costs. When evidence-based care is delivered
within an EBP culture and a context of car-
ing, the best patient outcomes are achieved
(Figure 1).

THE STEPS OF EVIDENCE-BASED
PRACTICE

To build HRHOs and EBP cultures, clini-
cians should learn and consistently implement
the steps of EBP, which include (1) cultivate
a spirit of inquiry; (2) ask clinical questions in
PICOT format, which stands for patient pop-
ulation of interest, intervention of interest,

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The ARCC Model for Systemwide Sustainability of EBP 131

Clinical decision
making

Quality
patient
outcomes

Research evidence
and evidence-based

theories

Clinical expertise (eg, evidence
from patient assessment, internal

evidence, and the use of health care
resources)

Patient preferences

Context of caring

EBP organizational culture

comparison intervention or group, outcome,
and time (eg, In intubated patients in the ICU
(P), how does early ambulation (I) vs delayed
ambulation (C) affect episodes of ventilator-
associated pneumonia (O) while in the ICU
(T)?); (3) search for the best evidence; (4) in-
tegrate the evidence with clinical expertise
and patient preferences to make the best clin-
ical decision; (5) evaluate the outcome(s) of
the EBP change; and (6) disseminate the out-
comes so that other patients can benefit. In
EBP, if there is enough high-quality evidence
from research to change practice, the prac-
tice is changed and outcomes are monitored
to support that the change in practice based
on research produces positive outcomes in
the real-world setting. If there is not enough
high-quality evidence to change practice, ex-
ternal evidence must be generated through
rigorous research or internal evidence pro-
duced through quality improvement or out-
comes management projects. High-reliability
health care organizations begin with leaders
and point-of-care providers who take the time
to think and reflect about the care that is be-
ing delivered and continually ask how it can
be improved, which is analogous to cultivat-
ing a spirit of inquiry or step 0 in the EBP
process.

CHARACTERISTICS OF BOTH
HIGH-RELIABILITY HEALTH CARE
ORGANIZATIONS AND EVIDENCE-BASED
PRACTICE CULTURES

There are many similarities between build-
ing an HRHO and an EBP culture. Character-
istics of both are included in the Table. Both
HRHOs and EBP cultures work to obtain the
highest levels of health care quality, safety,
and patient outcomes. Outcomes monitoring

Table. Characteristics of Both High-
Reliability Organizations and Evidence-
Based Practice Cultures

Commitment to delivering high-quality care
and patient safety and reducing costs

Strong leadership
Emphasis on process and systems design
Transdisciplinary teamwork
Effective communication
Delivery/standardization of best practices

and policies
An environment that promotes a spirit of

inquiry and continuous learning
Focus on continual process improvement
Outcomes monitoring/evaluation

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132 NURSING ADMINISTRATION QUARTERLY/APRIL–JUNE 2012

is a critical strategy in both HRHOs and EBP
cultures because outcomes reflect the impact
that is being made on health care quality, pa-
tient outcomes, and system outcomes.

BARRIERS TO AND FACILITATORS
OF ADVANCING HIGH-RELIABILITY
HEALTH CARE ORGANIZATIONS AND
EVIDENCE-BASED PRACTICE CULTURES

There are multiple barriers to leaders and
clinicians succeeding in developing an HRHO
and an EBP culture. Some of the major barri-
ers include (a) lack of knowledge and skills in
both HRHOs and EBP; (b) perceived lack of
time; (c) lack of organizational/administrative
support; and (d) educational programs that
continue to teach the “traditional way” with
a focus on producing research instead of us-
ing evidence to improve practice; and (e) lack
of mentorship.23-26 Conversely, facilitators of
building HRHOs and EBP cultures include
(a) knowledge and skills of HRHOs and EBP,
(b) beliefs that these types of organizations
and cultures improve care and patient out-
comes; (c) beliefs in the ability to implement
EBP and key concepts of HRHOs; (d) men-
tors who are skilled in EBP and HRHO con-
cepts; and (e) administrative/organizational
support, including leaders and managers who
model important behaviors related to EBP and
HRHOs.22,27,28

THE ARCC MODEL AS AN EXAMPLE OF
HOW BUILDING AN EVIDENCE-BASED
PRACTICE CULTURE FACILITATES A
HIGH-RELIABILITY HEALTH CARE
ORGANIZATION

Use of the EBP paradigm assists organi-
zations in achieving high reliability. There
is evidence to indicate that implementation
of evidence-based care helps reduce defects
in care processes, improves quality of care
and patient outcomes, standardizes care, de-
creases variations in care, increases efficiency
and decreases health care costs.1,22,25,29,30

The ARCC (Advancing Research and Clin-
ical practice through close Collaboration)

model is a systemwide model that can be used
by health care systems and hospitals for sus-
taining EBP and facilitating an HRHO (Figure
2). The ARCC model was first conceptualized
in 1999 as part of a strategic planning process
at a major medical center to rapidly integrate
research findings with clinical practice for the
ultimate purpose of improving quality of care
and patient outcomes. Four assumptions are
inherent in the ARCC model: (1) There are
barriers and facilitators of EBP for individu-
als and within health care systems. (2) Barri-
ers to EBP must be removed or mitigated and
facilitators put in place for both individuals
and health care systems to implement EBP as
standard of care. (3) In order for clinicians to
change their practices to be evidence-based,
cognitive beliefs about the value of EBP and
confidence about the ability to implement it
must be strengthened. (4) A culture of EBP
that includes EBP mentors (ie, clinicians with
advanced knowledge and skills in EBP, men-
torship, and individual as well as organiza-
tional change) is necessary to advance and
sustain evidence-based care.31

Implementation of the ARCC model be-
gins with an assessment of the culture and
readiness for EBP, which allows for the iden-
tification of strengths and limitations within
the health care system that either facilitate or
hinder the development of an EBP culture.
Next, a cadre of EBP mentors is developed
whose role is to address the limitations, en-
hance the strengths in the health care system
to build an EBP culture, and work directly
with point-of-care clinicians in implementing
and sustaining EBP. The ARCC model con-
tends that, when clinicians are mentored in
EBP, their cognitive beliefs about the value
of EBP and their ability to implement it are
strengthened, which results in greater imple-
mentation of EBP. Furthermore, when EBP is
implemented, there is improvement in patient
outcomes and clinician group cohesion and
job satisfaction, which ultimately results in
less turnover within the organization. To date,
several studies have been conducted that have
supported relationships among constructs in
the ARCC model.28,32,33,34

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The ARCC Model for Systemwide Sustainability of EBP 133

Figure 2. The ARCC model for systemwide implementation and sustainability of evidence-based practice
(EBP) can facilitate a high-reliability health care organization. Copyright 2005 Melnyk and Fineout-Overholt.
aScale developed. bBased on EBP paradigm and using the EBP process.

Implementation of the ARCC model is ac-
complished through a 12-month program to
prepare a cadre of EBP mentors who then
work with direct care staff to implement and
sustain EBP throughout the health care sys-
tem. Evidence-based practice mentors are typ-
ically advanced practice nurses or transdisci-
plinary professionals or clinicians with bach-
elor’s degrees. A series of 6 workshops with
8 days of educational and skills building ses-
sions are conducted over the yearlong ARCC
program, which is focused on implementing
the 7-step EBP process and necessary strate-
gies for building an EBP culture. Major con-
tent of the ARCC workshops includes (a) EBP
skills building; (b) creating a vision to mo-
tivate a change to EBP; (c) transdisciplinary
team building and effective communication;
(d) mentorship to advance EBP; (e) strate-
gies to build an EBP culture; (f) quality im-
provement processes; (g) data management

and outcomes monitoring/evaluation; and (h)
theories and principles of individual behav-
ior change and organizational change. Before
the first workshop, a baseline assessment is
conducted to assess the clinicians’ EBP be-
liefs, EBP implementation, organizational cul-
ture and readiness for EBP, job satisfaction,
and group cohesion. Patient data on problems
identified for improvement by the clinicians in
the ARCC program are also collected and ana-
lyzed. Each team that is attending the series of
workshops implements an EBP implementa-
tion project during the course of the 12-month
program focused on improving quality of care,
safety, and/or patient outcomes. Examples
of projects and outcomes from the most re-
cent implementation of the ARCC model at
the Washington Hospital Healthcare System,
a 355-bed community hospital system in the
Western region of the United States, include
the following: (a) Early ambulation in the ICU

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134 NURSING ADMINISTRATION QUARTERLY/APRIL–JUNE 2012

resulted in a reduction in ventilator days from
11.6 to 8.9 days and no ventilator-associated
pneumonias. (b) Pressure ulcer rates were re-
duced from 6.07% to 0.62% on a medical sur-
gical unit. (c) Education of patients with con-
gestive heart failure led to a 14.7% reduction
in hospital readmissions. (d) Seventy-five per-
cent of parents perceived the overall quality
of care as excellent after implementation of an
evidence-based family-centered care program
compared with 22.2% before implementation.

MAJOR FACTORS INFLUENCING
ADOPTION OF EVIDENCE-BASED
PRACTICES

There are a number of factors that can in-
fluence the adoption of EBPs. Some of these
factors include (a) the characteristics of the
EBP (eg, the strength of evidence to support
the practice, ease of administration, and cost);
(b) characteristics of the clinician (eg, the un-
derstanding and cognitive beliefs/confidence
to implement it and self-efficacy; (c) the envi-
ronment and culture of the organization; and
(d) the process through which the change
is implemented (eg, consensus building and

use of EBP mentors and opinion leaders).35,36

These same factors are likely to exist when ap-
plying concepts from HROs in health care or-
ganizations. For clinicians to implement best
practices and concepts from HROs, it must be
made easy and fun as they are overburdened
with patient loads and competing priorities.
In addition, routine recognition and apprecia-
tion for efforts should be built in on a regular
basis to recognize individuals and teams for
their efforts. Furthermore, building EBPs and
concepts from HROs into electronic medical
records may help improve quality of care and
patient safety, but too many reminders may
lead clinicians to ignore them.

CONCLUSION

Concepts from HROs are being built into
health care systems both to improve quality
of care and patient safety and to improve ef-
ficiency and reduce health care costs. Sub-
stantial overlap exists in building HRHOs and
EBP cultures. Implementation of the ARCC
model for systemwide implementation and
sustainability of EBP can assist organizations
in achieving high reliability.

REFERENCES

1. Pronovost PJ, Berenholtz SM, Goeschel CA, et al.
Creating high reliability in health care organizations.
Health Serv Res. 2006;41(4)(pt II):1599-1617.

2. Reinertsen JL, Clancy C. Keeping our promises: re-
search, practice and policy issues in healthcare re-
liability. A special issue of health services research
(Forward). Health Serv Res. 2006;10:1677-1689.

3. Sammer CE, Lykens K, Singh KP, Mains DA, Lackan
NA. What is a patient safety culture? A review of the
literature. J Nurs Scholarsh. 2010;42(2):156-165.

4. Leonard M, Frankel A, Simmonds T, Vega KB. Achiev-
ing Safe and Reliable Healthcare. Chicago, IL:
Health Administration Press; 2004.

5. Resar RK. Practical applications of reliability the-
ory. Making noncatastrophic health care processes
reliable: learning to walk before running in creat-
ing high reliability organizations. Health Serv Res.
2006;41(4)(pt II):1677-1689.

6. Kohn LT, Corrigan J, Donaldson MS. Institute of
Medicine. To Err Is Human: Building a Safer Health
System. Washington, DC: National Academies Press;
2000.

7. Carroll JS, Rudolph JW. Design of high reliability or-
ganizations in health care. Qual Saf Health Care.
2006;15(suppl 1):i4-i9.

8. McKeon LM, Oswaks JD, Cunningham PD. Safeguard-
ing patients. Complexity science, high reliability or-
ganizations, and implications for team training in
healthcare. Clin Nurse Spec. 2006;20(6):298-304.

9. Melnyk BM. Coping with unplanned childhood hos-
pitalization: effects of informational interventions on
mothers and children. Nurs Res. 1994;43(1):50-55.

10. Melnyk BM, Feinstein NF, Alpert-Gillis L, et al. Re-
ducing premature infants length of stay and im-
proving parents’ mental health outcomes with the
COPE NICU program: a randomized clinical trial.
Pediatrics. 2006;118(5):1414-1427.

11. Melnyk BM, Alpert-Gillis L, Feinstein NF, et al. Creat-
ing opportunities for parent empowerment (COPE):
program effects on the mental health/coping
outcomes of critically ill young children and their
mothers. Pediatrics. 2004;113(6):e597-e607. http://
pediatrics.aappublications.org/content/113/6/e597.
full.html. Accessed June 1, 2011.

LWW/NAQ NAQ200184 March 1, 2012 23:19

The ARCC Model for Systemwide Sustainability of EBP 135

12. Melnyk BM, Alpert-Gillis L, Feinstein NF, et al. Im-
proving cognitive development of LBW premature
infants with the COPE program: a pilot study of the
benefit of early NICU intervention with mothers. Res
Nurs Health. 2001;24:373-389.

13. Melnyk BM, Alpert-Gillis LJ, Hensel PB, Cable-Billing
RC, Rubenstein J. Helping mothers cope with a crit-
ically ill child: a pilot test of the COPE intervention.
Res Nurs Health. 1997;20:3-14.

14. Vulcan [Melnyk] BM, Nikulich-Barrett M. The ef-
fects of selected information on mothers’ anxiety lev-
els during their children’s hospitalization. J Pediatr
Nurs. 1988;3(2):97-102.

15. Melnyk BM, Feinstein N. Reducing hospital expen-
ditures with the COPE (Creating Opportunities for
Parent Empowerment) program for parents and pre-
mature infants: an analysis of direct healthcare neona-
tal intensive care unit costs and savings. Nurs Adm
Q. 2009;33(1):32-27.

16. Melnyk BM. The “so what” factor in a time of health-
care reform: conducting research & EBP projects that
impact healthcare quality, cost and patient outcomes.
Distinguished Research Lecturer paper presented at:
the proceedings of the Western Institute of Nursing
Conference; April 2011; Las Vegas, Nevada.

17. Hader R. The evidence that isn’t. Nurs Manag.
2010;41(9):22-26.

18. American Hospital Association. TrendWatch
Chartbook 2007: trends affecting hospitals
and health systems. http://www.aha.org/aha/
trendwatch/chartbook/2007/07chapter4.ppt#10.
Accessed June 1, 2011.

19. Buntin MB, Damberg C, Haviland A, et al. Consumer-
directed health care: early evidence about effects on
cost and quality. Health Aff. 2006;25(6):W516-W530.

20. Hines S, Luna K, Lofthus J, et al. Becoming a High Re-
liability Organization: Operational Advice for Hos-
pital Leaders. Prepared by the Lewin Group under
Contract No. 290-04-0011. Rockville, MD: Agency for
Healthcare Research and Quality; 2008.AHRQ Publi-
cation No. 08-0022.

21. Riley W. High reliability and implications for nursing
leaders. J Nurs Manag. 2009;17:238-246.

22. Melnyk BM, Fineout-Overholt E. Evidence-Based
Practice in Nursing & Healthcare: A Guide to
Best Practice. 2nd ed. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins; 2011.

23. Cabana MD, Slish KK, Evans D, et al. Impact of physi-
cian asthma care education on patient outcomes. Pe-
diatrics. 2006;117(6):2149-2157.

24. Hannes K, Vandersmissen J, De Blaeser L, Peeters
G, Goedhuys J, Aertgeerts B. Barriers to evidence-
based nursing: a focus group study. J Adv Nurs.
2007;60(2):162-171.

25. McGinty J, Anderson G. Predictors of physician com-
pliance with American Heart Association Guidelines

for acute myocardial infarction. Crit Care Nurs Q.
2008;31(2):161-172.

26. Melnyk BM, Fineout-Overholt E, Mays M. The
evidence-based practice beliefs and implementation
scales: psychometric properties of two new instru-
ments. Worldviews Evid Based Nurs. 2008;5(4):208-
216.

27. Melnyk BM. The evidence-based practice mentor: a
promising strategy for implementing and sustaining
EBP in healthcare systems. Worldviews Evid Based
Nurs. 2007;4(3):123-125.

28. Melnyk BM, Fineout-Overholt E, Giggleman M, Cruz
R. Correlates among cognitive beliefs, EBP im-
plementation, organizational culture, cohesion and
job satisfaction in evidence-based practice mentors
from a community hospital system. Nurs Outlook.
2010;58(6):301-308.

29. Williams DO. Treatment delayed is treatment denied.
Circulation. 2004;109:1806-1808.

30. PricewaterhouseCoopers’ Health Research Institute.
What works: healing the healthcare staffing shortage.
http://www.pwc.com/us/en/healthcare/publications
/what-works-healing-the-healthcare-staffing-shortage
.jhtml. Published 2007. Accessed June 1, 2011.

31. Melnyk BM, Fineout-Overholt E. ARCC (Advancing
Research and Clinical practice through close Col-
laboration). A model for system-wide implemen-
tation and sustainability of evidence-based prac-
tice. In: Rycroft-Malone J, Bucknall T, eds. Models
and Frameworks for Implementing Evidence-Based
Practice. Philadelphia, PA: Blackwell Publishing;
2010: 169–184.

32. Levin RF, Fineout-Overholt E, Melnyk BM, Barnes
M, Vetter MJ. Fostering evidence-based practice to
improve nurse and cost outcomes in a community
health setting: a pilot test of the advancing research
and clinical practice through close collaboration
model. Nurs Adm Q. 2011;35(1):21-33.

33. Wallen GR, Mitchell SA, Melnyk BM, et al. Implement-
ing evidence-based practice: effectiveness of a struc-
tured multifaceted mentorship programme. J Adv
Nurs. 2010;66(12):2761-2771.

34. Melnyk BM, Fineout-Overholt E, Feinstein NF,
et al. Nurses’ perceived knowledge, beliefs,
skills, and needs regarding evidence-based prac-
tice: implications for accelerating the paradigm
shift. Worldviews Evid Based Nurs. 2004;1(3):
185-193.

35. Gurses AP, Marsteller JA, Ozok AA, Xiao Y, Owens
S, Pronovost PJ. Using an interdisciplinary approach
to identify factors that affect clinicians’ compli-
ance with evidence-based guidelines. Crit Care Med.
2010;38(suppl):S282-S291.

36. Shojania KG, Grimshaw JM. Evidence-based quality
improvement: the state of the science. Health Aff.
2005;24(1):138-150.

Sustaining Evidence-Based Practice Through

Organizational Policies and an Innovative Model

The team adopts the Advancing Research and Clinical
Practice Through Close Collaboration model.

This is the 12th and last article in a series from the Arizona State University College of Nursing and Health Innovation’s
Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to
the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and
patient preferences and values. When it’s delivered in a context of caring and in a supportive organizational culture, the
highest quality of care and best patient outcomes can be achieved. The complete EBP series is available as a collection
on our Web site; go to www.ajnonline.com and click on Collections.

In July’s evidence-based prac-tice (EBP) article, Rebecca R., Carlos A., and Chen M. eval-
uated the outcomes of their rapid
response team (RRT) implemen-
tation project. Their findings in-
dicated that a significant decrease
in one outcome, code rates outside
the ICU, had occurred after im-
plementation of the RRT. This
promising finding, together with
many other considerations—such
as organizational readiness; clini-
cian willingness; and a judicious
weighing of all the costs, benefits,
and outcomes—encouraged the
EBP team to continue with plans
to roll out the RRT protocol
throughout the entire hospital
system. They also began to work
on presentations and publications
about the project so that others
could learn from their experience
and implement similar interven-
tions to improve patient outcomes.

USING EVIDENCE TO INFORM
ORGANIZATIONAL POLICY
Because Rebecca, Carlos, and Chen
are concerned about whether the
implementation of an RRT can be
sustained over time in their hospi-
tal, they want to take the neces-
sary steps to create a hospital- wide

RRT policy. Therefore, they make
an appointment with their hospi-
tal’s director of policies and pro-
cedures, Maria P., to share the
outcomes data they’ve gathered
from their project and to discuss
the project’s success so far. Maria
is impressed by the rigor of the
team’s sequential EBP process
and the systematic way in which
they’ve gathered the

outcomes

data. She reminds them that the

measurement of outcomes (inter-
nal evidence) plus rigorous re-
search (external evidence) result
in the best evidence-based orga-
nizational policies to guide the
high est quality of care in health
care institutions.

Maria volunteers to assist the
team in writing a new evidence-
based policy to support having an
RRT in their hospital. She suggests

that each recommendation in the
policy be supported by evidence.
Maria explains that once the pol-
icy is written, it needs to be ap-
proved by the hospital-wide policy
committee, representing all of the
health disciplines. Maria empha-
sizes that transdisciplinary health
care professionals and administra –
tors should routinely be involved
when planning and implementing
evidenced-based organizational

policies. She also reminds the EBP
team that translating evidence and
evidence-based organizational pol-
icies into sustainable routine clin-
ical practices remains a major
challenge for health care systems.

The new RRT policy written by
Rebecca, Carlos, and Chen with
Maria’s help is approved by the
hospital-wide policy committee
within three months. Now the

By Bernadette Mazurek Melnyk,
PhD, RN, CPNP/PMHNP, FNAP,

FAAN, Ellen Fineout-Overholt, PhD,
RN, FNAP, FAAN, Lynn Gallagher-

Ford, MSN, RN, NE-BC, and Susan
B. Stillwell, DNP, RN, CNE, ANEF

ajn@wolterskluwer.com AJN ▼ September 2011 ▼ Vol. 111, No. 9 57

It only takes one passionate, committed

person to spearhead a team vision to

improve care for patients and their families.

http://www.ajnonline.com

challenge for the team is to work
with clinicians across the hospital
system to implement it. The EBP
team schedules a series of presen-
tations throughout the hospital
to introduce the new RRT policy.
They rotate the days and times of
this in-service to capture as many
direct care clinicians as possible.
To ensure that all clinicians are
educated on the new policy, a da-
tabase is created to track in-ser-
vice attendees, and each hos pital
unit is asked to appoint a volun-
teer to deliver the presentation to
any clinicians who missed it. Post-
ers are created and buttons de-
signed as visual triggers to remind
staff to implement the new policy.

Throughout this process, the
EBP team learned that dissemi-

nation of evidence alone doesn’t
typ ically lead clinicians to make
a sustainable change to EBP, and
they were impressed by how im-
portant it was to have unit-based
champions reinforce the new pol-
icy.1 They also learned that it’s
critical to have an organizational
culture that supports EBP (such as
evidence-based decision making
in tegrated into performance ex-
pectations, up-to-date resources
and tools, ongoing EBP knowledge
and skills-building workshops,
and EBP mentors at the point of
care) in order for clinicians to con-
sistently deliver evidence-based
care.2

Since the process they followed
worked so well, the team believes
that their hospital needs to adopt

a model to guide and reinforce
the creation of a culture to sus-
tain the EBP approach they had
initiated through this project.
They review several EBP process
and system integration models
and decide to adopt the Advanc-
ing Research and Clinical Prac-
tice Through Close Collaboration
(ARCC) model because its key
strategy to sustain evidence-based
care is the presence of an EBP
mentor (a clinician with advanced
knowledge of EBP, mentorship,
and individual as well as organi-
zational change). With Carlos’s
success as an expert EBP mentor,
and the mentorship model work-
ing so well, they believe that de-
veloping a cadre of EBP

mentors

system-wide is key to the ongoing

58 AJN ▼ September 2011 ▼ Vol. 111, No. 9 ajnonline.com

Potential Strengths

Philosophy of EBP
(paradigm is system-wide)

Presence of EBP mentors
and champions
Administrative support

Clinicians’ beliefs about
the value of EBP and
ability to implement the
EBP processa

Identification of
strengths and major

barriers to EBP
implementation

EBP
implementationa, b

Decreased
hospital
costs

Potential Barriers

Lack of EBP
mentors and
champions

Inadequate EBP
knowledge and
skills

Lack of EBP
valuing

Implementation of
ARCC strategies

Interactive
EBP skills building

EBP rounds and
journal clubs

Improved
patient

outcomes

Nurse/clinician
satisfaction
Cohesion
Intent to
leave

Turnover

Development
and use of EBP

mentors

Assessment of
organizational

culture and
readiness for EBPa

Figure 1. The ARCC Model for System-Wide Implementation and Sustainability of EBP
ARCC = Advancing Research and Clinical Practice Through Close Collaboration; EBP = evidence-based practice.
a Scale developed.
b Based on the EBP paradigm and using the EBP process.

00
5,

M
el

ny
k

an
d

Fi
ne

ou
t-O

ve
rh

ol
t.

that this model be adopted, not
only for the nursing department,
but for all disciplines throughout
the organization.

THE EBP JOURNEY HAS JUST BEGUN
This series presented a case in-
volving a hypothetical medical–
surgical nurse and her colleagues
to illustrate how EBP can be suc-
cessfully implemented to improve
key patient outcomes. It’s impor-
tant that the process start with
an ongoing spirit of inquiry, and
that nurses always question the

evidence behind the care we pro-
vide and never settle for the sta-
tus quo. Never forget that it only
takes one passionate, committed
person to spearhead a team vi-
sion to improve care for patients
and their families. It also takes
persistence through the “charac-
ter builders” that are sure to
appear as the vision comes to
fruition.

Although the EBP team has
successfully completed their RRT
implementation project and its
incorporation as a hospital-wide
policy, their EBP journey has just
be gun. In fact, only days after the
project’s completion, Rebecca
asked Carlos another great PICOT
question: “In critically ill patients,
how does early ambulation com-
pared with delayed ambulation
affect ventilator-associated pneu-
monia in the ICU?” Carlos looked
at her and replied, as a great men –
tor does, “I will help you search
for the evidence and we will find

and organizational culture change.
These individuals, whether expert
system-wide mentors, advanced
practice mentors, or peer mentors,
are focused on helping point-of-
care clinicians to use and sustain
EBP and to conduct EBP imple-
mentation, quality improvement,
and outcomes management proj-
ects. When clinicians work with
EBP mentors, their beliefs about
the value of EBP and their ability
to implement it increase, and this
is followed by a greater achieve-
ment of evidence-based care.4

The ARCC model contends that
greater implementation of EBP
results in higher job satisfaction,
lower turnover rate, and better
patient outcomes. A series of
studies now support the empiri-
cal relationships in the ARCC
model.4-8

The ARCC model has been
and continues to be implemented
in hospitals and health care sys-
tems across the country with ex-
cellent results in quality of care and
patient outcomes. Valid and reli-
able instruments, such as the EBP
Beliefs and EBP Implementation
scales,6 are used to measure key
constructs in the model and, to-
gether with organizational culture
and readiness for EBP, help to de-
termine the model’s effectiveness.6

The EBP team discusses how
all the elements of the ARCC
model are an excellent fit for their
organization. They decide to make
a recommendation to the Shared
Governance Steering Committee

implementation and sustainabil-
ity of EBP in their organization.

SUSTAINING AN EBP CULTURE WITH THE
ARCC MODEL
In reviewing the ARCC model,
the EBP team finds that its aim is
to provide hospitals and health
care systems with an organized
conceptual framework to guide
system-wide implementation and
sustainability of EBP for the pur-
pose of improving quality of care
and patient outcomes. In addition,
this model can be used to achieve
a “high reliability” organization
(one that delivers safe and high-
quality care), decrease costs, and
improve clinicians’ job satisfaction.
Four assumptions are basic to the
ARCC model3:
• Both barriers to and facilitators

of EBP exist for individuals and
within health care systems.

• Barriers to EBP must be re-
moved or mitigated and facili-
tators put in place in order for
individuals and health care sys –
tems to implement EBP as a
standard of care.

• For clinicians to change their
practices to be evidence based,
both their beliefs about the
value of EBP and their confi-
dence in their ability to imple-
ment it must be strengthened.

• An EBP culture that includes
EBP mentors is necessary in
order to advance and sustain
EBP in individuals and health
care systems.
The first step in the ARCC

model is to assess the organiza-
tion’s culture and readiness for EBP
(see Figure 1). From that assess-
ment, the strengths and limita tions
of implementing EBP within the
organization can be identified. The
key implementation strategy in the
ARCC model is the development
of a cadre of EBP mentors, who
are typically advanced practice
nurses or clinicians with in-depth
knowledge of and skills in EBP
and in individual behavior change

ajn@wolterskluwer.com AJN ▼ September 2011 ▼ Vol. 111, No. 9 59

Developing a cadre of EBP mentors

system-wide is key to the ongoing

implementation and sustainability of

EBP in an organization.

Wiley-Blackwell; Sigma Theta Tau;
2010. p. 169-84.

4. Melnyk BM, et al. Nurses’ perceived
knowledge, beliefs, skills, and needs
regarding evidence-based practice: im –
plications for accelerating the para-
digm shift. Worldviews Evid Based
Nurs 2004;1(3):185-93.

5. Levin RF, et al. Fostering evidence-
based practice to improve nurse and
cost outcomes in a community health
setting: a pilot test of the advancing
research and clinical practice through
close collaboration model. Nurs Adm
Q 2011;35(1):21-33.

6. Melnyk BM, et al. The evidence-
based practice beliefs and implemen-
tation scales: psychometric properties
of two new instruments. Worldviews
Evid Based Nurs 2008;5(4):208-16.

7. Melnyk BM, et al. Correlates among
cognitive beliefs, EBP implementa-
tion, organizational culture, cohesion
and job satisfaction in evidence-based
practice mentors from a community
hospital system. Nurs Outlook 2010;
58(6):301-8.

8. Wallen GR, et al. Implementing
evidence-based practice: effectiveness
of a struc tured multifaceted mentor-
ship programme. J Adv Nurs 2010;
66(12):2761-71.

Practice. Contact author: Berna dette
Mazurek Melnyk, melnyk.15@osu.edu.
The authors have disclosed no potential
conflicts of inter est, financial or other-
wise.

REFERENCES
1. Melnyk BM, Wiliamson KM. Using

evidence-based practice to enhance
organizational policies, healthcare qual –
ity, and patient outcomes. In: Hinshaw
AS, Grady PA, editors. Shaping health
policy through nursing research. New
York: Springer Publishing Company;
2011. p. 87-98.

2. Melnyk BM, Fineout-Overholt E.
Evidence-based practice in nursing
and healthcare: a guide to best prac-
tice. Philadelphia: Wolters Kluwer
Health/Lippincott Williams and Wil-
kins; 2011.

3. Melnyk BM, Fineout-Overholt E.
ARCC (Advancing Research and Clini-
cal prac tice through close Collabora-
tion): a model for system-wide
implementation and sustainability of
evidence-based practice. In: Rycroft-
Malone J, Bucknall T, editors. Models
and frame works for implementing
evidence-based practice: linking evi-
dence to action. Oxford; Ames, IA:

the answer to your question—
because EBP, not practices steeped
in tradition, is the only way we
do it here!” ▼

Bernadette Mazurek Melnyk is associate
vice president for health promotion, uni-
versity chief wellness officer, and dean of
The Ohio State University College of Nurs –
ing in Columbus, where Lynn Gallagher-
Ford is director of Transdisciplinary
Evidence-Based Practice and Clinical
Innovation. Ellen Fineout-Overholt is
dean of Professional Studies and chair of
the Department of Nursing at East Texas
Baptist University in Mar shall, TX.
Susan B. Stillwell is clinical professor and
associate director of the Center for the
Advancement of Evidence-Based Practice
at Arizona State Univer sity in Phoenix.
At the time this article was written, Ber-
nadette Mazurek Melnyk was dean and
distinguished foundation professor of
nursing in the College of Nurs ing and
Health Innovation at Arizona State Uni-
versity, where Ellen Fineout-Overholt was
clinical pro fessor and director, and Lynn
Gallagher-Ford was clinical assistant pro-
fessor and assistant director, of the Center
for the Advancement of Evidence-Based

Original Article

A Test of the ARCC C© Model Improves
Implementation of Evidence-Based Practice,
Healthcare Culture, and Patient Outcomes
Bernadette Mazurek Melnyk, RN, PhD, CPNP/PMHNP, FAANP, FNAP, FAAN •
Ellen Fineout-Overholt, RN, PhD, FNAP, FAAN • Martha Giggleman, RN, DNP,
NEA-BC • Katie Choy, RN, DNP, CNS, NEA-BC

Keywords

ARCC,
evidence-based

practice,
organizational

culture,
patient outcomes

ABSTRACT
Background: Although several models of evidence-based practice (EBP) exist, there is a paucity
of studies that have been conducted to evaluate their implementation in healthcare settings.

Aim: The purpose of this study was to examine the impact of the Advancing Research and
Clinical practice through close Collaboration (ARCC) Model on organizational culture, clinicians’
EBP beliefs and EBP implementation, and patient outcomes at one healthcare system in the
western United States.

Design: A pre-test, post-test longitudinal pre-experimental study was conducted with follow-up
immediately following full implementation of the ARCC Model.

Setting and Sample: The study was conducted at a 341-bed acute care hospital in the western
region of the United States. The sample consisted of 58 interprofessional healthcare professionals.

Methods: The ARCC Model was implemented in a sequential format over 12 months with the
key strategy of preparing a critical mass of EBP mentors for the healthcare system. Healthcare
professionals’ EBP beliefs, EBP implementation, and organizational culture were measured with
valid and reliable instruments. Patient outcomes were collected in aggregate from the hospital’s
medical records.

Results: Findings indicated significant increases in clinicians’ EBP beliefs and EBP implementation
along with positive movement toward an organizational EBP culture. Study findings also indicated
substantial improvements in several patient outcomes.

Linking Evidence to Action: Implementation of the ARCC Model in healthcare systems can en-
hance clinicians’ beliefs and implementation of evidence-based care, improve patient outcomes,
and move organizational culture toward EBP.

INTRODUCTION AND BACKGROUND
It is well known that evidence-based practice (EBP) improves
healthcare quality, safety, and patient outcomes as well as fos-
ters clinicians’ active engagement in their practices. Nurses
who use an evidence-based approach to care and practice in
cultures that support EBP are more empowered as they are
able to make a difference in the care of their patients. Although
the positive impact of EBP has been demonstrated through
multiple studies, major barriers exist that prevent EBP from
becoming the standard of care throughout the world. These
barriers include (a) inadequate EBP knowledge and skills of
clinicians, (b) misperceptions that EBP takes too much time,
(c) organizational culture and politics, (d) lack of support from
nurse leaders and managers, and (e) inadequate resources and
investment in EBP (Jun, Kovner, & Stimpfel, 2016; Melnyk
et al., 2016; Melnyk, Fineout-Overholt, Gallagher-Ford, & Ka-

plan, 2012). Aside from equipping clinicians with the knowl-
edge and skills needed to attain the EBP competencies and con-
sistently implement evidence-based care, findings from studies
have indicated that clinician access to EBP mentors can play a
key role in their implementation of EBP and the development
of organizational cultures that support the delivery of evidence-
based care (Fineout-Overholt & Melnyk, 2015; Melnyk, 2007).

Although several EBP models exist, most are process mod-
els that outline the steps of EBP or the sequence of conducting
an EBP project. EBP process models include the Johns Hopkins
Nursing Evidence-Based Practice Model (Dearholt & Dang,
2012), the Iowa Model of Evidence-Based Practice to Promote
Quality Care (Titler et al., 2001), the Model for Evidence-Based
Practice Change (Rosswurm & Larabee, 1999), and the ACE
Star Model of Knowledge Transformation (Stevens, 2012).
Unlike EBP process models, the Advancing Research and

Figure 1. The Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model.

Clinical practice through close Collaboration (ARCC) Model is
a system-wide model to advance and sustain EBP in healthcare
systems (see Figure 1). The first step in implementing the
ARCC Model is an organizational assessment of the current
EBP culture in order to identify strengths and major barriers
to EBP in the healthcare system so that strategies can be
implemented to remove those barriers. At the core of the
ARCC Model is a critical mass of EBP mentors who, through
intentional strategic initiatives, assist point of care clinicians
in enhancing their beliefs about the value of EBP and their
confidence in implementing it. As a result, ARCC contends
that heightened EBP beliefs in clinicians result in greater
implementation of evidence-based care, which ultimately
leads to higher job satisfaction, less staff turnover, and
improved patient outcomes. Several studies now support the
relationships among key constructs in the ARCC Model (Levin,
Fineout-Overholt, Melnyk, Barnes, & Vetter, 2011; Melnyk,
2012; Melnyk & Fineout-Overholt, 2002; Melnyk et al., 2004;
Melnyk, Fineout-Overholt, & Mays, 2008; Melnyk, Fineout-
Overholt, Giggleman, & Cruz, 2010; Wallen et al., 2010).

AIM
The purpose of this study was to examine the impact of the
ARCC Model on organizational culture, clinicians’ EBP beliefs
and EBP implementation, and patient outcomes at one health-
care system in the western region of the United States.

DESIGN
A pre-test, post-test longitudinal pre-experimental study was
conducted with follow-up immediately following full imple-
mentation of the ARCC Model. Institutional Review Board ap-
proval was obtained from the authors’ institution as well as the
organization’s research subject review board.

SETTING AND SAMPLE
This study was conducted at Washington Hospital Healthcare
System, a 341-bed acute care hospital in the San Francisco
bay area. The sample consisted of 58 interprofessional health-
care professionals, with complete follow-up data for 45 partic-
ipants. Participants were point of care nurses, administrators,
nurse managers, clinical nurse specialists, respiratory thera-
pists, occupational therapists, physical therapists, dieticians,
social workers, and pharmacists. Although physician cham-
pions participated in the projects, they were not part of the
data collection. Only the project teams participated in data
collection.

METHODS
The ARCC Model was implemented in a sequential format
over 12 months with the key strategy of preparing a critical
mass of EBP mentors for the healthcare system. Intensive EBP
workshops were first provided to the 58 participants in order
to enhance their knowledge and skills in the seven steps of

Original Article
Table 1. Examples of PICOT Questions Formulated
by the EBP Teams

� In ventilated intensive care unit patients (P), howdoes early
ambulation (I) compared to routinely scheduledambulation
(C) affect length of stay andepisodesof ventilator
associatedpneumoniawhile in the intensive care unit (T)

� In congestive heart failure patients (P), howdoes
comprehensive pre-discharge education (I) compared to
standardpre-discharge education (C), affect readmission
rates to thehospital (O)?

EBP. In addition, content and skills building in the workshops
focused on how to facilitate individual behavior change of clin-
icians to implement EBP and how to facilitate an EBP organi-
zational culture. The 58 participants were divided into working
teams of six to eight members who were to collaborate on
an EBP change project to improve patient outcomes within
the hospital. Each team was then charged with formulating
a PICOT (Patient population, Intervention or Issue of inter-
est, Comparison intervention or issue, Outcome, and Time for
the intervention to achieve the outcome if relevant) question
about an important clinical issue, systematically searching for
the best evidence, and critically appraising and synthesizing
the evidence culminating in a recommendation for practice.
See Table 1 for examples of PICOT questions developed by
the teams. Strategic plans were then developed by the inter-
professional EBP mentor teams to implement and evaluate the
impact of the EBP changes on clinical outcomes within their
organization. After implementation and evaluation of the prac-
tice changes were completed, the final step for the teams was
to submit their projects for presentation at local, regional, or
national conferences to disseminate their successes to others
within the healthcare community.

OUTCOMES
Study variables were measured with the following valid and reli-
able instruments. The Evidence-Based Practice Beliefs (EBPB)
Scale Melnyk & Fineout-Overholt, 2003a) measured clinicians’
beliefs about EBP and their ability to implement it. The 16-item
Likert scale has established face, content, and construct valid-
ity with internal consistency reliabilities greater than .85 across
multiple studies (Melnyk et al., 2008). Responses on the scale
range from 1 (strongly disagree) to 5 (strongly agree). Examples
of items on the scale include (a) I am clear about the steps in
EBP, (b) I am sure that I can implement EBP, and (c) I am sure
that evidence-based guidelines can improve care.

The Evidence-Based Practice Implementation (EBPI) Scale
measured delivery of evidence-based care (Melnyk & Fineout-
Overholt, 2003b). Participants respond to each of the 18 Likert
scale items on the EBPI by answering how often in the last
eight weeks they have performed certain EBP activities, such as
(a) generated a PICOT question about my practice, (b) used evi-

dence to change my clinical practice, (c) evaluated the outcomes
of a practice change, and (d) shared the outcome data collected
with colleagues. The EBPI has established face, content, and
construct validity as well as internal consistency reliabilities
greater than .85 across multiple studies (Melnyk et al., 2008).

The Organizational Culture and Readiness Scale for
System-Wide Integration of Evidence-Based Practice (OCR-
SIEP) measured the organization’s culture and its readiness
for system-wide EBP (Fineout-Overholt & Melnyk, 2006). This
instrument contains 26 Likert scale items that identify a de-
scription of the existing support in the current culture for EBP,
which offers insight into the strengths and opportunities for
fostering evidence-based care within a healthcare system. The
OCRSIEP scale has established face and content validity along
with excellent internal consistency reliability of greater than .85
across multiple samples (Melnyk & Fineout-Overholt, 2015).
Examples of items on the OCRSIEP include the following:
(a) To what extent is EBP clearly described as central to the
mission and philosophy of your institution? (b) To what extent
do you believe that EBP is practiced in your organization? And
(c) To what extent is the nursing staff with whom you work
committed to EBP?

Patient Outcomes
Aggregate data were gathered by the teams, including data
from the hospital’s medical records (e.g., number of cases of
ventilator associated pneumonia, hospital readmission rates)
before and after implementation of the ARCC Model to evaluate
relevant patient outcomes as results of the EBP projects.

Analyses
T tests and effect sizes were calculated for study variables to
evaluate pre-to-post differences. A p value of .05 was set for
statistical significance.

RESULTS
Findings indicated that the clinicians’ EBP beliefs, EBP im-
plementation, and movement of organizational culture toward
EBP significantly increased over the 12-month project. Specif-
ically, clinicians’ EBP beliefs (n = 45) increased significantly
from baseline (M = 60.7, SD = 7.6) to follow-up (M = 64.9,
SD = 6.7; t = 4.2; p = .00; effect size = .62, which is a medium
to large positive effect for ARCC). EBP implementation also
significantly increased from baseline (M = 17.8, SD = 10.3) to
follow-up (M = 51.9, SD = 16.8; t = 12.9; p = .00; effect size =
2.3, indicating a large positive effect for ARCC). In addition,
organizational culture and readiness for EBP increased signifi-
cantly from baseline (M = 80.9; SD = 90.8) to follow-up (M =
90.8; SD = 14.7; t = 3.9; p = .00; effect size = .70, which
is a medium to large positive effect for ARCC). In addition,
as a result of implementing the ARCC Model, evidence-based
interventions improved key patient outcomes (see Table 2).

Table 2. Project Outcomes From Implementation
of the EBP Changes

� Apractice change to early ambulation in the ICU led to a2.7
reduction in ventilator days (11.6–8.9) andno ventilator
associatedpneumonia.

� With the implementation of apressure ulcer prevention
nursing standardizedprocedure onamedical-surgical unit,
the acquiredpressure ulcer ratewas significantly decreased
from6.07%to0.62%1year later.

� Comprehensive educationof congestive heart failure
patients led to a 14.7%reduction in hospital readmissions.

� After implementation of family centered care on the
pediatric unit, 75%of parents perceived theoverall quality
of care as excellent compared to22%pre-implementation.

� Thepercentageofmothers not supplementing their breast
milkwith formula increased from61.7% to71.1%after the
evidence-basedbaby friendly hospital initiativewas
implemented.

� After implementation of a nurse-initiatedpain protocol in
the emergency room(ER),wait time for painmedication
decreased from46minutes to 13minutes and length of stay
in theERalsodecreased from120minutes to91minutes.

DISCUSSION
Findings support the positive impact of implementing the
ARCC Model on clinicians’ EBP beliefs and a dramatic in-
crease in EBP implementation in those who participated in the
project. Organizational culture at the hospital shifted greatly
toward system-wide EBP. Most important, as a result of imple-
menting ARCC, there were multiple improvements in patient
outcomes.

The establishment of a cadre of EBP mentors is cen-
tral to building an organizational culture of EBP and im-
plementing evidence-based care. The EBP mentors in this
study garnered the knowledge and skills needed to successfully
implement and evaluate EBP changes within the hospital as
well as to work with their colleagues in creating an EBP culture
in which to deliver high-quality evidence-based care. These
findings affirm that culture eats strategy and assists clini-
cians in making EBP the social norm within a system (Mel-
nyk, 2016b). Without a culture and environment that supports
EBP, high-quality evidence-based care will not sustain (Melnyk,
2016a).

Numerous healthcare systems and hospitals throughout the
United States and globe have implemented the ARCC Model in
their efforts to build and sustain an EBP culture and environ-
ment in their organizations. As a part of building this culture,
position descriptions have been created or changed to include
responsibilities as an EBP mentor. For example, at The Ohio
State University Wexner Medical Center, the primary responsi-
bility of the clinical nurse specialists throughout the healthcare
system is to serve as EBP mentors for point of care staff in
improving patient outcomes. Part of this role is ensuring

compliance with the EBP competencies for advanced practice
nurses (Melnyk, Gallagher-Ford, & Fineout-Overholt, 2016;
Melnyk, Gallagher-Ford, Long & Fineout-Overholt, 2015).

Research is needed to further confirm the advantages of
using particular EBP models in real-world practice settings,
including how implementation of these models impact both
clinician, leader and patient outcomes (Dang et al., 2015). Com-
parative effectiveness studies that evaluate the benefits of in-
dividual models as well as combining models also are needed.
Those hospitals and systems who use an EBP model to guide
implementation of evidence-based care should document their
experiences and outcomes in order to better understand the
model’s usefulness in facilitating EBP and share this impor-
tant information with others who might use the model (Gra-
ham, Tetroe, & KT Theories Research Group, 2007). Return
on investment by including cost outcomes also should be eval-
uated. WVN

LINKING EVIDENCE TO ACTION

� The ARCC Model is an evidence-based system-
wide model for advancing the implementation and
sustainability of EBP.

� A key strategy in the ARCC model is the develop-
ment of a critical mass of EBP mentors who assist
point of care clinicians in the consistent imple-
mentation of evidence-based care.

� Use of ARCC EBP mentors enhances the EBP be-
liefs and EBP implementation of clinicians and
strengthens the EBP culture of an organization.

� An organizational culture of EBP is central to sup-
porting sustainable high quality evidence-based
care.

� Implementation of the ARCC Model can substan-
tially improve patient outcomes.

Author information

Bernadette Mazurek Melnyk, Associate Vice President for
Health Promotion, University Chief Wellness Officer, Dean
and Professor, College of Nursing, Professor of Pediatrics &
Psychiatry, and College of Medicine, The Ohio State Univer-
sity, Columbus, Ohio; Ellen Fineout-Overholt, Mary Coulter
Dowdy Distinguished Professor of Nursing, College of Nurs-
ing & Health Sciences University of Texas at Tyler, Tyler, Texas;
Martha Giggleman, Healthcare Consultant & Advocate Liver-
more, California; Katie Choy, Senior Director, Nursing Practice
and Education, Washington Hospital Healthcare System, Fre-
mont, California

Original Article
Address correspondence to Dr. Bernadette Mazurek Melnyk,

The Ohio State University, 145 Newton Hall, 1585 Neil Avenue,
Columbus, OH 43210; Melnyk.15@osu.edu

References
Dang, D., Melnyk, B. M., Fineout-Overholt, E., Ciliska, D., Di-

Censo, A., Cullen, L., . . . & Stevens, R. K. (2015). Models to
guide implementation and sustainability of evidence-based prac-
tice. In B. M. Melnyk & E. Fineout-Overholt (Eds.) Evidence-based
practice in nursing & healthcare. A guide to best practice (3rd ed.,
pp. 274–315). Philadelphia, PA: Wolters Kluwer.

Dearholt, S. L., & Dang, D. (2012). Johns Hopkins nursing evidence-
based practice model and guidelines (2nd ed.). Indianapolis, IN:
Sigma Theta Tau International.

Fineout-Overholt, E., & Melnyk, B. M. (2015). ARCC evidence-
based practice mentors: The key to sustaining evidence-based
practice. In B. M. Melnyk & E. Fineout-Overholt (Eds.) Evidence-
based practice in nursing & healthcare. A guide to best practice (3rd
ed., pp. 376–385). Philadelphia, PA: Wolters Kluwer.

Fineout-Overholt, E., & Melnyk, B. M. (2006). Organizational cul-
ture and readiness scale for system-wide integration of evidence-based
practice. Gilbert, AZ: ARCC, llc.

Graham, I. D., & Tetroe, J. & the KT Theories Research Group.
(2007). Some theoretical underpinnings of knowledge transla-
tion. Academic Emergency Medicine, 14(11), 936–941.

Jun, J., Kovner, C. T., & Stimpfel, A. W. (2016). Barriers and
facilitators of nurses’ use of clinical practice guidelines: An
integrative review. International Journal of Nursing Studies, 60,
54–68.

Levin, R. F., Fineout-Overholt, E., Melnyk, B. M., Barnes, M., &
Vetter, M. J. (2011). Fostering evidence-based practice to improve
nurse and cost outcomes in a community health setting: A pilot
test of the advancing research and clinical practice through close
collaboration model. Nursing Administration Quarterly, 35(1), 21–
33.

Melnyk, B. M. (2007). The evidence-based practice mentor: A
promising strategy for implementing and sustaining EBP in
healthcare systems. Worldviews on Evidence-Based Nursing, 4(3),
123–125.

Melnyk, B. M. (2012). Achieving a high-reliability organization
through implementation of the ARCC model for system wide
sustainability of evidence-based practice. Nursing Administration
Quarterly, 36(2), 127–135.

Melnyk, B. M. (2016a). An urgent call to action for nurse lead-
ers to establish sustainable evidence-based practice cultures and
implement evidence-based interventions to improve healthcare
quality. Worldviews on Evidence-Based Nursing, 13(1), 3–5.

Melnyk, B. M. (2016b). Culture eats strategy every time: What
works in building and sustaining an evidence-based practice cul-
ture in healthcare systems. Worldviews on Evidence-Based Nurs-
ing, 13(2), 99–101.

Melnyk, B. M., & Fineout-Overholt, E. (2002). Putting research
into practice. Reflections on Nursing Leadership, 28(2), 22–25.

Melnyk, B. M., & Fineout-Overholt, E. (2003a). Evidence-based prac-
tice beliefs scale. Gilbert, AZ: ARCC Publishing.

Melnyk, B. M., & Fineout-Overholt, E. (2003b). Evidence-based prac-
tice implementation scale (3rd ed.). Gilbert, AZ: ARCC Publishing.

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based prac-
tice in nursing and healthcare: A guide to best practice. Philadelphia,
PA: Lippincott, Williams & Wilkins.

Melnyk, B. M., Fineout-Overholt, E., Fischbeck Feinstein, N., Li,
H., Small, L., Wilcox, L., & Kraus, R. (2004). Nurses’ perceived
knowledge, beliefs, skills, and needs regarding evidence-based
practice: Implications for accelerating the paradigm shift. World-
views on Evidence-Based Nursing, 1(3), 185–193.

Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan,
L. (2012). The state of evidence-based practice in U.S. nurses:
Critical implications for nurse leaders and educators. Journal of
Nursing Administration, 42(9), 410–417.

Melnyk, B. M., Fineout-Overholt, E., Giggleman, M., & Cruz, R.
(2010). Correlates among cognitive beliefs, EBP implementa-
tion, organizational culture, cohesion and job satisfaction in
evidence-based practice mentors from a community hospital
system. Nursing Outlook, 58(6), 301–308.

Melnyk, B. M., Gallagher-Ford, L., & Fineout-Overholt, E. (2016).
Implementing the evidence-based practice competencies in healthcare.
A practical guide for improving quality, safety and patient outcomes.
Indianapolis, IN: Sigma Theta Tau International.

Melnyk, B. M., Fineout-Overholt, E., & Mays, M. (2008). The
evidence-based practice beliefs and implementation scales: Psy-
chometric properties of two new instruments. Worldviews on
Evidence-Based Nursing, 5(4), 208–216.

Melnyk, B. M., Gallagher-Ford, L., Thomas, B. K., Troseth, M.,
Wyngarden, K., & Szalacha, L. (2016). A study of chief nurse
executives indicates low prioritization of evidence-based practice
and shortcomings in hospital performance metrics across the
United States. Worldviews on Evidence-based Nursing, 13(1), 6–14.

Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change
to evidence-based practice. Image: Journal of Nursing Scholarship,
31(4), 317–322.

Stevens, K. R. (2012). Star model of EBP: Knowledge transformation.
Academic Center for Evidence-based Practice, TX: The Univer-
sity of Texas Health Science Center at San Antonio.

Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau,
G., Everett, L. Q., & . . . Goode, C. J. (2001). The Iowa Model
of evidence-based practice to promote quality care. Critical Care
Nursing Clinics of North America, 13(4), 497–509.

Wallen, G. R., Mitchell, S. A., Melnyk, B. M., Fineout-Overholt, E.,
Miller-Davis, C., Yates, J., & Hastings, C. (2010). Implement-
ing evidence-based practice: Effectiveness of a structured mul-
tifaceted mentorship programme. Journal of Advanced Nursing,
66(12), 2761–2771.

doi 10.1111/wvn.12188
WVN 2017;14:5–9

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Notes

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As you narrate or provide speaker notes for your presentation, the general rule is that each slide is approximately 1 minute. This being the case, you will have to expand upon the information that is on the slide

-A typical PowerPoint slide should contain clear and concise wording. Full paragraphs are not used on slides. It is important to consider your audience and make sure they are engaged in the presentation. You do not need to narrate your reference slide.

This was just a note from the professor telling me to be as specific as possible:

-What are the rates of readmission? Be as specific as possible. If one of big issues is increased readmission, the primary measurable would be to decrease readmission rates. It would be important to be specific here such as, reduce readmission rates by 10%, or something to that effect.

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