Learning From Lessons for Change

Field: Health Professions (Health Sciences)

Welcome to the inaugural issue of the Quality Improvement Showcase: Lessons for Change, an exciting, new extension of the AORN Journal designed to spotlight the important quality improvement (QI) work that perioperative personnel across the world are performing daily in their facilities. The mission of the QI Showcase is to advance perioperative care by serving as a venue for clinicians to publish and share a wide range of QI initiatives that underpin evidence-based practice (EBP), which is the cornerstone of perioperative practice. Improving practice, testing new ways of delivering and providing care, and exploring the impact of perioperative innovation is no longer reserved for scientists and those working in the top tier of academic medical centers. Clinicians across all clinical settings are expected to use EBP in their daily practice, as demonstrated by evidence-based Joint Commission requirements, ANCC Magnet requirements, and AORN Guidelines for Perioperative Practice.1 Globally, curious perioperative clinicians have engaged in a range of QI work, from foundational to groundbreaking projects. Many of these QI initiatives have shown positive results, some lack statistical significance yet yield clinical significance, and others provide important learning lessons for other perioperative settings. The QI Showcase will publish information in a more flexible and inclusive format than is traditionally found in most peer-reviewed journals and will regularly feature a variety of reports, brief reports, and posters. Quality improvement is defined as “the deliberate application and/or implementation of knowledge in local settings that has been previously discovered, typically through primary research.”2(p334) Although primary research is essential for exploring, identifying, and systematically discovering and testing new knowledge, the application of these findings in local settings, such as your OR, is necessary to evaluate whether the study results are, in fact, effective in improving quality care at your institution. Local context makes an enormous difference—what works in one unit, surgical service, or hospital, or on a particular shift, may not work for all. Simply because an intervention is statistically significant in producing a particular outcome at a given study site does not guarantee that the same intervention will be helpful in your unit. This is the power of QI work: to apply already discovered knowledge and evaluate the change in a local setting. The manuscripts chosen for this first issue highlight many, if not all, of these steps and describe completed QI projects or spotlight one or two aspects of the five steps of EBP. Many believe that the dissemination of lessons learned is the sixth step of EBP, even when those lessons are not statistically significant or do not meet the rigor of internationally accepted standards. The notion of rigor and the scientific method can be traced back to Aristotle, widely considered to be the father of science.4 Scientific methodologies have become increasingly more sophisticated and specialized, and much of this is driven by the desire to increase rigor. The National Institutes of Health defines rigor as, “the strict application of the scientific method to ensure robust and unbiased experimental design, methodology, analysis, interpretation and reporting of results. This includes full transparency in reporting experimental details so that others may reproduce and extend the findings.”5 The emphasis on rigor in modern times can, in part, be traced to the genesis of reporting guidelines, where there is an increased focus on the steps of the scientific process in a greater attempt to reduce bias and increase the quality of the reported material. In turn, journals became increasingly interested in publishing only the most rigorous research and those studies that demonstrated statistical significance. Research that is unable to show statistical significance between an intervention and a control group or between two or more interventions is often called a negative trial, and reports of these studies rarely get published.6 Often, negative trials are underpowered, which is another way of describing an effect size that is too small given the study sample. In short, the intervention is not powerful enough to demonstrate with statistics that it made a difference, given the number of study participants. A poorly conceived or conducted research project is another explanation for lack of statistical significance. Yet, a negative trial only refers to the statistics behind the analysis and does not address the meaningfulness or clinical significance of the findings. Although the Journal team members involved in the conception of the QI Showcase fully support strong, rigorous science with limited bias, we likewise understand the complexity and nuanced nature of clinical environments and recognize that many clinical issues are often solved with non-standardized tools that make sense for the QI project at hand. We understand that small sample sizes and an abbreviated data collection period may be necessary in the rapid-fire pace of a busy perioperative area. We also appreciate that some projects do not achieve statistical significance but can show very real clinical significance—it made a difference in practice! For that reason, we are pleased to offer you lessons learned by others in the hope that they inspire meaningful change in your hospitals and units. We are currently seeking author submissions for the next Quality Improvement Showcase that will be published in 2021. For more information and to view the Author Guidelines, visit www.aornjournal.org/qualityimprovement. If you have any questions, please send an e-mail to aornjournal@aorn.org. Daphne Stannard, PhD, RN, CNS, NPD-BC, FCCM, is the associate editor for Quality Improvement for the AORN Journal and for the QI Showcase: Lessons for Change and an associate professor at San Francisco State University, CA. Dr Stannard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.