“The Stevens STAR Model of Knowledge Transformation” by Kathleen Stevens

Hello. I’m Kathleen Stevens, a Professor at the University
of Texas Health San Antonio. I’ve been a pioneer of evidence-based practice
for a while, because of my belief that it’s crucial to transform health care with the
research that we discover. Our patients will enjoy better outcomes when
we implement that research into practice. Hello. My name is Ethan Schuler. I’m an Acute Care Nurse Practitioner at Boston
Children’s Hospital in the Medical-Surgical ICU. I am also the Chair of the Evidence-based
Practice Subcommittee at Boston Children’s Hospital. Today, I have the pleasure of introducing
Dr. Kathleen Stevens, Professor of nursing at the University of Texas Health, San Antonio. Dr. Stevens served for 15 years as founding
director of the Academic Center for Evidence-Based Practice and pioneered the field. The Center of Excellence and Improvement Science
Research Network generated over 12 million to advance evidence-based quality improvement
and patient safety. She initiated and guided the annual Summer
Institute on Evidence-Based Practice, a national interdisciplinary conference. Dr. Stevens serves on the Board of Directors
of the Association for Clinical and Translational Science. She is a fellow of the Academy of Nurse Educators
and American Academy of Nursing, Episteme Laureate in Nursing and named into the International
Nurse Researcher Hall of Fame. Dr. Stevens, welcome to OPENPediatrics. We are so thrilled to have you here today. I like to get started by asking a question. Could you tell me a little bit about what
prompted you to develop this Stevens Star Model? Well, Ethan, it’s a joy to be here. It’s my pleasure to share the story about
the Star Model. It happened that I was a pediatric nurse and
became very interested in research. And when I did– I found out that it wasn’t
the day-to-day hand touching of nurse to patient. But it was a very extended kind of delayed
gratification. And it occurred to me that research is just
so important. But it’s a delayed gratification. It takes so long to do without it moving to
help patients with their outcomes. So I began thinking about what it would take
to move research into direct patient care to produce the outcomes we intended. So the Star Model was born out of that passion
for moving research into practice. Can you give us some historical context about
how that came to be? Evidence-based practice was considered, perhaps,
a suspect for being a fad back in the 1999 era. However, it was really solidly galvanized
when the Institute of Medicine published a report on the errors that were made in health
care. To Err is Human was a shocking revelation
of how many people were harmed by the very health care that they sought to solve their
health issues. And right after that 1999, 2000 publication,
the Institute of Medicine published a report that became a blueprint for how to transform
health care using six principles. It’s called Crossing the Quality Chasm. And the six principles are to generate a health
care delivery system that was safe, timely, effective, evidence-based, equitable, and
patient-centered. So those S-T-E-E-E-P principles still resonate,
although, that report came out in 2001. And as I was working in the field, pioneering,
believing in evidence-based practice, because, as I said, research is just too tedious not
to make it have a payload for the patient. It occurred to me that the idea that was promoted
in chapter 6 of Crossing the Quality Chasm on evidence-based practice really was worthy
of making it reachable by most health professions and certainly in nursing. So the Star Model came about in thinking about
what works in health care. There was an IOM 2008 publication, saying,
well, what works in health care, we really need to know, because those are the interventions
to carry forward for our patients and family. Then a couple of more reports on what works
highlighted systematic reviews and clinical practice guidelines, which are part and parcel
of the essence of evidence-based practice and therefore, the Star Model. So in the early days, those reports didn’t
really exist. And I was connecting people with the idea
of moving research to practice and kept listing the same five steps until it occurred to us
as a group that, perhaps, this could be a five-point star. The Stevens Star Model has five points. Can you walk me through them? The five points of the Stevens Star Model
identify the transformation that knowledge has to undergo in order to inform clinical
decisions. So, well, that’s where we want to go with
our original research on point one of the star. So that’s the first point is discovery research. The second point is, now that we have multiple
research projects on the same topic of, does this intervention produce the intended outcome,
we need to amass it and synthesize it or summarize it to be helpful. For the third point of the star, which is,
clinicians sit down and look at the massive evidence the summary that was generated through
a systematic review and where there is missing evidence, missing research, clinical expertise
is added there. And the output of that particular process
is a clinical practice guideline that is based on the best available evidence combined with
the clinical expertise that fills in the gaps. Moving to point 4 of the star, we have this
wonderful program, now, and recommendations that we know this works in health care. But bringing it to the front line and thinking
about, how do we get it implemented or integrated into our usual practice? So point four of the star is called practice
integration. And the idea is to hardwire this new practice
into the kind of care that we give with high excellence to our patients. And, of course, the fifth point of the star
is to think about, did we produce the impact? Did we produce the impact that we wanted in
individual clinicians providing the care, in patients that receive the care and moving
their health outcome to a better status? And in the organization, understanding that
this learning process, as an organization, is part and parcel of their excellence of
the services that they provide to the community. I’d like to stop now and ask our colleagues
around the world a question. In your response, please leave your city and
country location. The question is, what helps facilitate evidence-based
practice in your facility? Describe an approach you have found successful
for implementing a change in your institution. What are some effective ways that a bedside
nurse who’s going through this process of knowledge transformation can do in order to
be an agent of change? Evidence-based practice in our discipline
is, number one, a shared activity across disciplines, because our practices are interwoven. And since evidence-based practice has been
studied in the processes for producing discovery research or evidence summaries, or translation
to guidelines, those processes have been stabilized. So carrying the evidence-based practice forward
into practice integration represents a new field– a new field that’s been spurred on
by the clinical and translational science awards here out of the National Institute
for Health. And the National Institute for Nursing Research
is part of that activity. We know less about how to change that behavior,
because when you show up in the clinical practice setting, although your counsel has built a
very strong evidence-based clinical practice guideline, it represents a change in behavior
for the clinician. We’re in a high-risk business. And we like to hold onto something that we
think works. So showing up with the best evidence takes
a leap of faith into understanding how that evidence was produced. And that becomes a transparent activity. And as the frontline provider looks at that
transparency and says, yes, I know that we’re following the best process for taking evidence
and moving it into recommendations so that I can integrate it into care becomes a real
high trust type of activity that helps a great deal. But implementation strategies that work include
things, like, setting a scientific standard for this is the way we will do this and implement
it, packaging that clinical practice guideline to where it’s accessible to the clinician. And the clinician says, OK, I will implement
it now– show me how. So a champion is very often a strategy that’s
used for practice facilitation. Setting the standard and getting everybody
to agree on the team that this is the standard provides an opportunity for a second type
of intervention. And that is audit feedback. We’ve set the standard. We’ve looked at your behavior. Let’s reflect on those clinical decisions. Are they matching our standard? So that’s audit feedback. And it offers an opportunity for reflective
practice and self-correction to that scientific standard. Let’s see. Another way is the necessary education to
have a person’s thinking change from the old practice to the new practice. But that doesn’t get the action just yet. So sometimes that championing and academic
detailing is an important part of changing practice. Dr. Stevens, can you speak about the key stakeholders
that are involved who would utilize knowledge to affect health care outcomes? Absolutely. The change agent has to interact with probably
four levels of stakeholders. The first one, of course, is the individual
clinician. They have a lot at stake in terms of giving
up their old practice for the new. The next is the care team. And that care team adjusts and bounces off
of each other as a microsystem to hold steady the practice that is in place. The third level is the organizational level
that has the policy and what’s the procedure followed. And then the fourth one is this external environment
of policy payers, the community expectations. So those four levels all have an impact on
the change and receive the change in a different way. How important is a team-based approach and
change implementation? The delivery of health care services requires
a team approach because we deliver it as a team. Each of us is embedded in a complex adaptive
system that requires us to think broadly and in terms of system, and not only microsystem,
but macrosystem. So teaming across all stakeholders is crucial
if something is changed that affects pharmacy. Then they need to be involved. And sometimes we forget housekeeping is also
involved. And sometimes we forget, you know, all these
different facets of our complex adaptive system that when we change one thing, it sometimes
affects another aspect. And so the idea of complexity theory is one
that is fairly new in nursing. Systems thinking is fairly new in nursing. And so it’s really, really exciting to think
about what disciplines can inform us as we move forward in our complex adaptive systems. And in our system thinking, people like systems
engineers, can be very helpful. Industrial engineers are all about the process
and flow through. And there are many questions about improving
care that we can turn to health economist to help us with the return on investment. So you see, as we think about what kind of
bridge we need to build to get research into practice through this system environment that
the complex adaptive system is a huge part of the attention that we need to pay as change
agents. As a collaborative– It is collaborative. It requires a team that is totally focused. When they come together as a team, not that
that’s their whole life. But that’s their work on this particular project
during that particular time that they all share and lift toward the same goal. And so that’s the shared mental model that’s
so important in change management. Can you talk about the state of where you
see implementation science five, ten years down the road from now? I would be happy to project– what I see implementation
science evolving into– I believe in the United States that the National Institutes of Health,
Clinical and Translational Science Award Program has set in motion an awareness for dissemination
and implementation. And in order to build principles that we can
employ on point four of the star, those integration principles, the implementation research can
evolve and test what strategies work in promoting uptake of that evidence-based guideline. So the idea of building a science is one that
starts out pretty messy. It’s everybody’s labeling different things. There are over 60 theories that have been
advanced on different parts of the process of implementation. And I know that, as I’ve seen evidence-based
practice become consolidated, so will implementation research become consolidated into this science
of sound principles. And it is starting out as a beautiful interprofessional
aspect of health care that people from a number of disciplines come together. And the discipline playing field is really
leveled at several of the conferences that are promoting and advancing dissemination
and implementation. So in the meantime, things, like, theories
are being developed. There’s one theory that is rising above all
the rest. And it will become more commonly used, not
that there’s no room for another one because there are different aspects, as you can see,
of implementation. There are new competencies that are being
agreed upon in terms of, these are the competencies that we need to conduct implementation research. It’s a new field of research. And so our scientific workforce capacity needs
to be brought up to the point where we can produce and write great grants and generate
those strategies that have been evaluated that are effective. In addition to the competencies for implementation
research, there’s implementation practice, I think, that can evolve in terms of the issues
that we’ve talked about today. What does the frontline, middle management,
supervisory, overall arching policy people, what do they need to understand about using
the principles from that science, because that’s what science is for. It explains how things work. And so if we can build that science and turn
to practitioners, clinicians, administrators and say, here’s how it works. You press it here. And you can cause that to happen. You do an audit feedback mechanism. And you can get 60% certainty that you’re
going to get a change in behavior. Then we’ve really delivered what needs to
be delivered to clinicians who are transforming health care delivery. So in the future, implementation science will
grow to be a more crystallized science. And right now, we’re just great explorers
in finding it and creating and inventing new designs and new statistical approaches. So the field is moving quickly. I think that in 10 years, we’d have a solid
science to deliver to clinicians and practitioners who want to apply the science. You’ve highlighted how critical it is to get
buy in from providers and clinicians and members of the health care team. How critical is it to also have input from
the patient? The patient is included in evidence-based
practice in several places, as you do academic practice partnering clinicians and providers
and patients and parents are part of even that point one of the star. But as it rolls around the traditional systematic
review using Cochran’s approach, engages patients and a broader set of academic and professional
organizations. Certainly in point 3 where the guideline is
being developed, your patient advocacy groups are important. But when it comes to deliver the care on point
four of the star. And you show up with the best practice saying,
you’ve come to us for services. We’re matching the best practice with your
particular condition. We believe this has a high likelihood of getting
you to your goal of better health. It is a partnership and a negotiation with
the parents and the patient of whether or not they actually want that best practice. Sometimes it’s a matter of informing and changing
their perception. And sometimes it’s a matter of giving them
options. So patient preferences really enter heavily
on point four of the star. So the Stevens Star Model has been around
for nearly 20 years. And you’ve highlighted how our health care
system has evolved so much in just that short amount of time. How has your model adapted and changed over
time to meet that evolving climate? It has remained surprisingly stable and the
same. The first Star Model, the graphics were a
little rougher. But the idea behind point one, two, three,
and four have not changed. Some additional words have been added so that
it communicates and is much more accessible for a quick view of transforming knowledge
into practice. The biggest change, I think, conceptually
that occurred was on point four, our integration. Initially, it was called implementation. And history has circled me back around to
be working in the field of implementation science. But at that point, I really thought all you
had to do was implement. And it comes to mind that what has to happen
is a true integration, a hard wiring, a deep-seated rooting of this evidence into everyone’s practice
so that it becomes not evidence-based practice but the way we do things here. Now, this is our new standard. And it’s embedded with science and patient
preference and clinical expertise. So point four has changed just a little bit,
although I’m returning to it with a new science called implementation science. And point four now is called the integration
to reflect that, really, shift at a learning health care organization level and a shift
in culture of being open to being nimble and transformative in our health care. It’s funny that you just brought up the same
word that I was just about to ask was, shifting organizational culture, because that’s one
of the known difficulties in trying to implement this kind of work. And so I think that you have a keen insight
onto how important it is to get that buy in. So that you can use science and evidence in
order to change that culture. That’s a really good point. I think that we take seriously the services
and what our work really is. And we become risk-averse, because human lives
and human health hang in the balance. And so we tighten up around what we know works
in our routines. And to loosen that up and have the trust in
the evidence and the process that delivers it to the front for care, is major in terms
of building that culture of trust. And how important is it to have this change
but then also to go back and look at the repercussions of this change and the outcomes associated
with that? So the five points of the Star Model culminate
in the fifth point which is evaluation. And we know that implementing a change– first
of all, it’s very painful for folks. But getting them beyond that and having the
clinician satisfied with this new practice is one of those very real outcomes. Of course we want the patient and the parents
and the community happy with the shift in health outcome and population outcome. And then we hope to have some kind of level
of impact on policy in terms of, how do we stabilize this through our local policy and
national policy? So evaluation becomes an issue of, how do
we sustain the change? Part of it is return on investment because
change is never cheap. And then making the change stick, you know,
not floating back into old habits is all served with benchmarks and report cards. And the encouragement that, yes, this was
a hard shift. And we were novices with this new practice. And it’s become very productive in terms of
increasing the excellence of our care, as well as the patient outcome. I’d like to turn a final time to our audience
and ask a question. In your answer, please leave your city and
country location. The question is, is there a standard timeline
for reviewing clinical practice guidelines in your institution? If not when should they be reviewed? For a new nurse who is just beginning to delve
into evidence-based practice, and somebody that may have that passion for change but
doesn’t necessarily know how to go about it, what words of advice do you have for someone
who has this deep-seated need to be an agent of change but are just at the beginning of
their journey? In part, the answer to that question is, the
expert panels that I put together to define the essential competencies for evidence-based
practice in nursing. And it was amazing to me out of those 83 statements,
they’re divided into basic, intermediate, and advanced. A number of them focused on change and change
agents. One of them focused on not necessarily being
what we call the leader but acknowledging that we have to have good followers, trusting
followers who are aware of the process and believe in the process and will take that
risk under a leader to move it forward. And today, they may be a follower. Or I may be a leader. And tomorrow, I may be a follower with a new
practice. So that balance of leadership and followership
is a really high-level kind of idea that new graduates can come into the clinical setting
with. Can you talk more in-depth about the steps
to change management? So change management really has been studied
a great deal by the business field, because as businesses generate new products, new services,
the aspects of having the adoption embraced is the source of their continuation. So this comes out of the business field. But there are eight change management strategies. The first is, to create a sense of urgency
that this has to change. We can’t proceed this way because there’s
impending– there’s impending harms. There’s impending loss. There’s impending situations that are not
as good as they could be. So creating that sense of urgency is crucial
to the next step of building a guiding team. There will be people that you invite in. And there will be people that are naturally
drawn to the particular issue. That team, then, has some work to do in terms
of getting their central point. I happen to use a yellow sticky. For any particular project and write it on
the yellow sticky and keep that in front of me, it’s called developing a change vision
and strategy are in this field of change management. It’s called a shared mental model. So having a shared mental model is essential
to all group work. Or else, you’d be pulling in all different
directions. Having people who aren’t those early adopters
really get on board in terms of buying in and understanding the benefits of the change,
and what it would require in terms of their own practices is very important, and then
empowering them. The supply sometimes are affected. Sometimes, it’s the educational material for
the patients. Sometimes, it’s the physical layout. So the high reliability organization aspects
really go into empowering others and celebrating those short-term wins in seeing the progress,
the interim process adopted before you even get to the outcomes is really important–
badges and stars and awards and posters and announcements to underscore and hold solid
to this course of change. So the short-term wins are very important. And then we all can get very excited early
on. But we can’t let up. You have to be relentless in change management
in saying, this is good. Let’s keep pushing. Is it working? Can we streamline something? Until finally, you receive at the level eight
of change management, a new culture of values and practices that are totally embraced by
that whole system, by that whole group, as this is the way we do things here. And it is elevated to this very high level
of a standard of science. How has that change sustained over time? So change is sustained over time by reinforcement. Being pediatric backgrounds, we know about
reinforcing and extinguishing behavior. So reinforcement depends on which level of
the process you’re at for the clinician, for the administrator. So the return on your investment of effort
and attention and time and risk taking has to be seen. That return has to be seen so that it would
be sustained. And that’s part of being relentless. So yes, there’s a dollar amount that can be
attached to it. But there is also these– I call them distant
dollar amounts– that have to do with patient satisfaction and parents returning to your
services and the joy that nurses receive, and work and the decrease in the turnover
of the nursing staff. So all of these things sustain that change. I’m not certain that we can always point to
a single incident of, we implemented this evidence-based practice guideline. And we got all of this magnificent culture
change. But it takes all of that to move to a learning
health care organization and create that culture of safety, that culture of change, that culture
of transformation. You bring up an interesting point in that
we can affect patient outcomes. But we can also affect clinician outcomes,
as well, in terms of creating a healthier work environment, leading to more job retention
over time, job satisfaction, as well. And I think that’s a very important point. Indeed, it is. Your own hospital has been highlighted for
creating an excellent work environment for nurses. And we know from research that nurses who
work in a safe environment not only where the nurse-patient ratio is a good nurse patient-ratio,
but also, this acceptance of, we will have failures. Remember the first report was called To Err
is Human. If we learn from those, we have to be that
learning organization to go back and plug those holes so that those safety issues go
away. A nurse feels safe, then. There’s a safety net and the excitement of
working in a place that you enjoy working in. And it leads directly underscored by research
evidence into safer care provided by the staff. Dr. Stevens, you’re an insightful and respected
leader in this field of work. And we’d like to thank you very much for your
time today. And you’ve really brought home how a nurse
in the context of a health care organization, in the context of a national movement to improve
care for our patients, and how all that is interrelated. And we’d like to thank you for all these insights
that you’ve shared with us today that we can implement here at Boston Children’s Hospital. So, thank you again for being with us today. It’s been my pleasure. You’re very welcome.

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