7.2 Evidence-Based Practice, Clinical Audit & Quality Improvement

Evidence-Based Practice, Clinical Audit & Quality Improvement

Quality improvement and evidence-based practice are central tenets of professional nursing in Aotearoa New Zealand. Registered Nurses are required under Nursing Council of New Zealand (NCNZ) Competency Domain 4 to contribute to continuous quality improvement, critically evaluate research findings, and apply evidence to enhance patient safety and healthcare equity.

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1. Evidence-Based Practice (EBP) in Nursing

Evidence-Based Practice (EBP) is defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. EBP synthesizes three foundational components:

                  ┌───────────────────────────────────────────┐
                  │       Best Available Research Evidence    │
                  └─────────────────────┬─────────────────────┘
                                        │
                                        ▼
    ┌─────────────────────────┐   ┌───────────────────────────┐
    │ Clinical Expertise &    ├══►│  Evidence-Based Nursing   │
    │ Professional Judgment   │   │     Clinical Decision     │
    └─────────────────────────┘   └─────────────┬─────────────┘
                                                │
                                                ▼
                  ┌───────────────────────────────────────────┐
                  │ Consumer Values, Cultural Preferences &   │
                  │           Whānau Priorities               │
                  └───────────────────────────────────────────┘

The PICO/PICOT Framework for Clinical Inquiry

To search for high-quality evidence efficiently, nurses structure clinical questions using the PICO (or PICOT) format:

• P (Population / Patient / Problem): Specific patient demographic or clinical condition (e.g., adult surgical patients with indwelling urinary catheters).
• I (Intervention): The proposed clinical intervention or practice (e.g., nurse-led catheter removal protocol).
• C (Comparison): Standard care or alternative intervention (e.g., physician-ordered catheter removal).
• O (Outcome): Desired measurable outcome (e.g., reduction in catheter-associated urinary tract infections [CAUTIs] and hospital length of stay).
• T (Timeframe): Duration of evaluation (e.g., within 30 days post-operatively).

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2. Hierarchy of Evidence

Not all clinical evidence carries equal scientific weight. When reviewing literature to update clinical guidelines or nursing procedures, RNs categorize evidence according to established evidence hierarchies:

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3. The Clinical Audit Cycle

A clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit, evidence-based criteria and the implementation of change.

The 5 Stages of the Audit Cycle

1. Stage 1 — Select Topic & Define Standards: Identify a clinical issue (e.g., surgical site infection rates) and select explicit, evidence-based standards (e.g., pre-operative antiseptic skin preparation guidelines).
2. Stage 2 — Data Collection: Audit patient records or observe practices to collect baseline data over a defined timeframe.
3. Stage 3 — Compare Performance Against Standards: Analyze audit data to determine compliance percentages and identify practice gaps.
4. Stage 4 — Implement Change: Develop and execute targeted interventions (e.g., staff education, new skin prep kits, checklist integration) to address root causes of non-compliance.
5. Stage 5 — Re-Audit (Closing the Loop): Repeat data collection after a set period to measure the impact of interventions and confirm sustained improvement.

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4. The Plan-Do-Study-Act (PDSA) Quality Improvement Model

The Plan-Do-Study-Act (PDSA) cycle, developed by Deming and popularized by the Institute for Healthcare Improvement (IHI), is widely utilized across New Zealand District Health networks for rapid-test quality improvement initiatives.

                  ┌──────────────────────────────────────────┐
                  │                1. PLAN                   │
                  │  • Define objective & change hypothesis  │
                  │  • Plan data collection & task allocation│
                  └────────────────────┬─────────────────────┘
                                       │
                                       ▼
  ┌─────────────────────────┐                    ┌─────────────────────────┐
  │         4. ACT          │                    │          2. DO          │
  │ • Adapt, Adopt or Abandon│                    │ • Execute test on small │
  │ • Prepare next cycle or │                    │   scale                 │
  │   scale up change       │                    │ • Document problems &   │
  └─────────────────────────┘                    │   unexpected data       │
               ▲                                 └────────────┬────────────┘
               │                                              │
               │                  3. STUDY                    │
               └──────────────────────────────────────────────┘
                 • Analyze data against baseline predictions
                 • Summarize key learnings & unexpected outcomes

Phases of the PDSA Cycle

• Plan: State the objective, formulate a clear prediction/hypothesis, identify data collection metrics, and plan who will do what, when, and where.
• Do: Carry out the test on a small, manageable scale (e.g., testing a new fall risk assessment tool on a 5-bed sub-unit for 3 days). Document unexpected problems and collect observation data.
• Study: Complete data analysis, compare results against initial predictions, evaluate process metrics, and summarize key insights learned.
• Act: Based on findings, determine the next step: Adopt (implement the change hospital-wide), Adapt (modify the intervention and run a refined PDSA cycle), or Abandon (discard the change if evidence shows no benefit or harm).

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5. Health Quality & Safety Commission (HQSC) Aotearoa Initiatives

The Health Quality & Safety Commission (HQSC) leads national quality and safety programs across New Zealand. Key national safety priority areas include:

• National Patient Safety Markers (PSMs): Benchmarked indicators tracking clinical compliance in areas such as:
  • Fall Prevention: Individualized fall risk assessments and care plans (e.g., "Safe Practice, Effective Care").
  • Pressure Injury Prevention: Routine skin risk scoring (Waterlow/Braden scales) and pressure-relieving surface deployment.
  • Hand Hygiene New Zealand (HHNZ): Observational auditing of the WHO 5 Moments for Hand Hygiene.
  • Surgical Safety Checklist: Pre-incision "Time Out" verification in operating theatres.
  • Central Line-Associated Bacteraemia (CLAB) Prevention: Insertion and maintenance aseptic bundles in ICU settings.
• Adverse Event Reporting & Root Cause Analysis (RCA): Systems like RiskMan or Datix facilitate transparent event reporting. Serious Adverse Events (SAC 1 and SAC 2 ratings) undergo structured Root Cause Analysis (RCA) to uncover systemic vulnerabilities rather than assigning individual fault, driving a just culture focused on organizational learning.