Making Wishes Known: An Evidence-Based Practice Project for Advanced Care Planning in Oncology

Practice Problem: An advance directive is a tool that patients use to maintain control of their care, plan for potential life events, identify their health proxy and communicate their wishes with their healthcare team. Despite the stated importance, the percentage of patients with completed advance directives in the Oncology clinic was less than 10%. This meant that the majority of patients did not have the tools to make their wishes known to the healthcare team. PICOT: The PICOT question that guided this EBP project is In adult oncology patients within the outpatient setting, does implementing a formal advanced care planning (ACP) process as compared to usual practice affect completion of advance directives over 8 weeks? Evidence: Evidence revealed that incorporation of the ACP process into patient interactions by members of the healthcare team increase patients’ completion of advance directives. EMR documentation is evidenced to provide the team with ease of use and ability to track the ACP process. Intervention: The project incorporates the ACP process into patient interactions with the staff. Incorporation of the ACP process and completion rates for advance directives are drawn from EMR data. Outcome: There was no statistical difference in the percentage of patients who had advance directives after four weeks. However, the project highlights how nurses in ambulatory care affect metrics associated with quality outcomes through patient advocacy. Furthermore, the project provides a process for nurses to provide their patients the resources they need to take control of their care. The project will be sustained because of the clinical significance. Conclusion: A formalized ACP process improves ambulatory nursing care by providing patients with resources to make their wishes known. 4 MAKING WISHES KNOWN Making Wishes Known: An Evidence-Based Practice Project for Advanced Care Planning in Oncology Cancer is one of the most devastating disease conditions in the United States (Centers for Medicare & Medicaid Services [CMS], n.d.). According to Epstein et al. (2019), “...no measure of the quality of cancer care is more important than the concordance of care with the patient’s core health-related values” (p. 72). Advance care planning (ACP) is a process that provides the patient a means to communicate their values, wishes, and goals with their healthcare team (Bestvina & Polite, 2017; Bires et al., 2017; Brinkman-Stoppelenburg et al., 2014; Epstein et al., 2019; Hamilton, 2020). Despite the benefits, the percentage of oncology patients that have completed the elements of ACP is still not significant (Bires et al., 2017; Waller et al., 2019). Moreover, without documentation of advance directives, the benefits of having the ACP conversations does not get realized (Waller et al., 2019). Nurses who work with oncology patients are well-positioned to enhance ACP efforts (Epstein et al., 2019). Nurse-led interventions have been shown to increase patients’ comfort in having ACP conversations, improve overall patient satisfaction and documentation of advance directives (Epstein et al., 2019; Hoverman et al., 2017). The following manuscript elaborates on the implementation of an evidence-based practice (EBP) project for nurses to help increase completion of advance directives by using ACP process. Significance of the Practice Problem Epstein et al., (2019) wrote that “...failure to align treatment with [patients’] values is viewed as a medical error” (p. 72). ACP provides healthcare systems the mechanism to know the patients’ values and provide patient-centered care (Bires et al., 2017; Epstein et al., 2019). 5 MAKING WISHES KNOWN Advance directives that come out of ACP provide the healthcare team with clear direction on how to align the treatment plan with what the patients’ desire (Hoverman et al., 2017).


Making Wishes Known: An Evidence-Based Practice Project for Advanced Care Planning in Oncology
Cancer is one of the most devastating disease conditions in the United States (Centers for Medicare & Medicaid Services [CMS], n.d.). According to Epstein et al. (2019), "…no measure of the quality of cancer care is more important than the concordance of care with the patient's core health-related values" (p. 72). Advance care planning (ACP) is a process that provides the patient a means to communicate their values, wishes, and goals with their healthcare team (Bestvina & Polite, 2017;Bires et al., 2017;Brinkman-Stoppelenburg et al., 2014;Epstein et al., 2019;Hamilton, 2020). Despite the benefits, the percentage of oncology patients that have completed the elements of ACP is still not significant (Bires et al., 2017;Waller et al., 2019).
Moreover, without documentation of advance directives, the benefits of having the ACP conversations does not get realized (Waller et al., 2019).
Nurses who work with oncology patients are well-positioned to enhance ACP efforts (Epstein et al., 2019). Nurse-led interventions have been shown to increase patients' comfort in having ACP conversations, improve overall patient satisfaction and documentation of advance directives (Epstein et al., 2019;Hoverman et al., 2017). The following manuscript elaborates on the implementation of an evidence-based practice (EBP) project for nurses to help increase completion of advance directives by using ACP process. Epstein et al., (2019) wrote that "…failure to align treatment with [patients'] values is viewed as a medical error" (p. 72). ACP provides healthcare systems the mechanism to know the patients' values and provide patient-centered care (Bires et al., 2017;Epstein et al., 2019).

Significance of the Practice Problem
Advance directives that come out of ACP provide the healthcare team with clear direction on how to align the treatment plan with what the patients' desire (Hoverman et al., 2017).

Impact to Outcomes
There is significant evidence to highlight the benefits of ACP. Advance care planning has been shown to extend the patients' autonomy, reduce the patients' and families' anxieties, and increase alignment with the patients' end-of-life wishes, thereby improving overall patient satisfaction (Brinkman-Stoppelenburg, 2014). Hamilton (2020) wrote that "…improving patient experience has an inherent value to patients and families and is therefore an important outcome in its own right" (p. 8). Patients who complete their advance directives after ACP have been shown to choose less-aggressive care and still receive higher quality care (Hoverman et al., 2017). Furthermore, completion of advance directives through ACP has been associated with improved patient experience, important financial indicators and improved clinical outcomes (Hamilton, 2020).
Among patients diagnosed with cancer, having clear documentation of their care preferences is even more critical. In previous decades, care provided to cancer patients especially at the end-of-life have led to increased health costs that are inversely proportional to their benefit (Waller et al., 2019). Many cancer patients receive painful aggressive therapies at the end of life including unnecessary hospital admissions and demise (Waller et al., 2019). Such experiences could be prevented by having advance directives and alignment to the documented patients' wishes (Waller et al., 2019).

Standards of Care
In 2013, the Institute of Medicine (IOM) cited ACP as an important quality indicator in the provision of care for oncology patients (Levit et al., 2013). Professional organizations, such as the American Society of Clinical Oncology (ASCO), advocate for the implementation of ACP as a standard of care for oncology patients (Narang et al., 2015;Peppercorn et al., 2011). In response, Centers for Medicare & Medicaid Services [CMS] (2016) developed the Oncology Care Model (OCM) that, in part, required ACP in oncology patients for hospital systems to be paid for services to their oncology population.

Current Practice
The organization for the project recognized the importance of ACP in all aspects of care provision especially with the oncology patients. The current practice around ACP involves conversations with providers at random points in the continuum of care. The nurses who work in the oncology department are not active participants in the ACP process. There is no data to capture how the ACP process leads to completion of advance directives. The percentage of adult oncology patients with completed advance directives in their EMR has been around 10% for the past two years.

PICOT Question
The PICOT question that guided this EBP project is In adult oncology patients within the outpatient setting, does implementing a formal advanced care planning process as compared to usual practice affect completion of advance directives over 8 weeks?
The population of interest were adult oncology patients 18 and older who are seen at the outpatient Oncology Clinic of the practicum site. The population included patients who do not have documented advanced directives or Physician Order of Life Sustaining Treatment (POLST) in their EMR. This included all patients seen at the clinic regardless of the type of cancer diagnosis and the time they were diagnosed. The intervention involved the implementation of the ACP process into patient interactions. There is currently no specific process utilized in the oncology department to increase completion of advance directives. The usual practice for the medical center involves unstructured conversations between the patient and their providers at random points of their diagnosis. The outcome measurement was the percentage of patients with completed advance directives in their EMR. The timeframe for the implementation is four weeks.

Evidence-Based Practice Framework and Change Theory
Melnyk and Fineout-Overholt (2019) related the importance of using models for EBP and change to successfully implement an EBP practice change. The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) model was incorporated as the EBP model and Kotter's 8step process for leading change was used for the project.

Johns Hopkins Nursing Evidence-Based Practice Model
The JHNEBP model provides steps that can align evidence with practice . This model was selected for the project implementation for its streamlined approach to problem-solving and practical application. The model involves the three steps: practice question, evidence, and translation . Following the JHNEBP model, the next steps were to review the best available evidence around ACP and how it affected completion of advance directives. The evidence in the literature serves as the foundation for the changes to nursing care related to the EBP project.

Kotter's Change Model
Kotter's change model includes eight steps to accelerate change used to implement the EBP project. Kotter's model outlines two fundamental reasons that drive change: to increase revenue or reduce costs, and become more effective or efficient (Kotter, 2020). As connoted by Kotter's model an eight-step process leads to change: 1) create a sense of urgency, 2) build a strong coalition, 3) form a strategic vision, 4) enlist a volunteer army, 5) enable action by removing barriers, 6) generate short-term wins, 7) sustain acceleration, and 8) institute change.
Kotter's 8-step model fit well with the organization's current culture. The organization has a culture that encourages innovation and practice changes, and involvement of key stakeholders in developing any change project's mission. The organization's leadership understood that the success of change projects involves active participation from the nurses and other members of the healthcare team. They also recognized that their role as leaders is served by removing barriers and celebrating early wins with the staff and the patients. The leaders appreciated that successful practice changes are ones that are sustained and yield long-term results for the patients as well as meeting objectives for the organization.

Evidence Search Strategy
The databases used for the literature search were CINAHL, PubMed and OVID. These databases were used because of their availability from the University of St. Augustine (USA) Library as well as that of the implementation site. The MESH search phrases used were (oncology OR cancer OR neoplasm) AND (advance* care plan* OR advance* directive OR code status) AND (electronic medical record OR electronic health record OR EMR OR EHR) AND (code status OR documentation OR completion). Inclusion criteria were research articles with all adult population. Filters were applied to narrow the search to peer-reviewed articles published in the English language. The search was not limited to full text articles only to ensure that all articles that met the criteria were reviewed. The search time frame used was from 1995 to current; this was to ensure that relevant articles published earlier could be appraised for inclusion in the body of evidence. The strategy included ancestry search of articles that were initially reviewed. Excluded from the evidence reviewed were articles that cited strategies that did not include EMR processes, those conducted in the inpatient areas such as the intensive care units (ICU) or emergency departments (ED) and studies pending results. The PRISMA diagram is included in the appendix as Figure 1.

Evidence Search Results
The search strategy indicated above yielded a total of 234 abstracts that were reviewed.
The inclusion and exclusion criteria were used to further evaluate the abstracts to ensure appropriateness. From these abstracts, 26 articles emerged as meeting the set criteria relating to the EBP project. There were five duplicate articles which narrowed down the number of articles reviewed to 21. Upon further review, 12 of these articles were not included in the evidence appraisal. Some of these excluded articles did not specify the EMR intervention implemented, had outcomes associated with patient engagement or clinician confidence, or had ongoing data collection or analysis. Five more articles were included after conducting a manual search of included references in the articles. Ultimately, there are 14 articles included in the body of evidence used to guide the EBP study process. The evidence tables with the included articles, their level and quality are included as (Appendix A and B) of the proposal.
Four of the articles are included in the evidence are systematic reviews. The number of articles included in the systematic reviews ranged anywhere from 15 to 113. Overall, there were a combined 161 articles between the systematic reviews.
There are ten primary source evidence articles that are included in the evidence review.
Of these, there were two articles that were published before 2010. The decision to include these articles despite their age was made because of how they were cited multiple times in the other articles.
The JHNEBP Evidence Level and Quality Guide tool  was used to appraise the articles included in the evidence. There was one level I article, seven that were level II and six that were level III. There were 10 articles that had high quality, generalizable findings, three that were good quality and one article that was low quality.
Overall, the evidence included articles that were randomized and non-randomized, quasiexperimental and non-experimental. The overall quality of the evidence is high with results that have statistically significant implications. Using the Strength of Recommendation Taxonomy (SORT) definitions (Ebell et al., 2004), the body of evidence from the literature search was level 1 as it has good-quality patient-oriented evidence. Therefore, using the same SORT definitions by Ebell et al. (2004), the strength of recommendation is A as it was based on consistent and good-quality patient-oriented evidence.

Themes with Practice Recommendations
The evidence review revealed several themes around using a structured process such as ACP, leveraging EMR capabilities, and involving members of the interprofessional team other than physicians.

Recommendations
The review of the literature answered the PICOT question affirmatively; in other words, in adult oncology patients, the incorporation of a formal ACP process in the nurses' interaction increased the documentation of advance directives in comparison to usual care.
Based on the overall review of the literature and a rigorous synthesis of the evidence, there are a few recommendations to address the identified practice problem. These recommendations were incorporated into the EBP project. The steps of the project involves 1) incorporation of ACP by the nurses in interactions with patients who meet criteria, 2) acknowledgement of EMR alert, 3) use of template to document ACP into EMR, and 4) involvement of members of the healthcare team other than the physicians to make changes in practice. The steps of the EBP project are included (as Appendix C).

Incorporation of ACP
The recommendation is for ACP to be incorporated into the Oncology clinic nurses' interaction with the patients. This includes an overview of the importance of having completed advance directives, the importance of identifying a healthcare decision maker, and information on resources around ACP that the patient can access (e.g. workshops, website).

EMR Alert and Documentation Template
It is recommended to use the EMR alerts to prompt clinicians to address oncology patients who do not have any advance directives on their charts yet. It is also recommended for the EMR to be organized so the physicians and other members of the healthcare team could use a documentation template to capture any conversations related to ACP and advance directives.

Engagement of Health Care Team
The EBP project involves engagement of members of the healthcare team beyond just the physician to improve completion of advance directives. Nurses could be involved by incorporating ACP into their patient interactions, directing patients to ACP resources, and providing follow up with patients and physicians for incomplete documentation of advance directives.

Setting, Stakeholders, and Systems Change
The organization in which the EBP change project occurred is a service area of a large integrated health system in southern California. The health system integrates hospital services with that of the medical group and health plan. It also provides care across the continuum from in-patient, outpatient and home health services. The organization's mission is to provide highquality affordable healthcare that is accessible to its patients and provided with a personal touch (Kaiser Permanente, n.d.). The project was implemented in the outpatient Oncology clinic. This project was implemented in the department with participants being adult oncology patients without advance directives or POLST on record.
The organization takes great pride in its interprofessional collaboration and their collective focus in making improvements in their care delivery. Organizational leaders recognized the need to improve documentation of advance directives and incorporate ACP into oncology. Early consultation with the chief nursing officer (CNO) was employed to start identifying stakeholders for successful implementation. Aside from the CNO, other stakeholders identified were physician leaders, the local expert for ACP, department manager or department administrator (DA), regional consultant for ACP, frontline staff, information technology (IT) consultant and workflow consultant. Organizational support was confirmed by having a combined meeting with the stakeholders as previously noted.
The sustainability plan involves the incorporation of the recommended process into the nurses' current practice of the department. Incorporation of ACP into existing practice helps ensure that this is regarded as an improvement effort for better outcomes. Involvement of the local ACP expert and a regional consultant ensure that the project is sustained with both local and regional leadership support. Challenges that may involve technical aspects involving the IT infrastructure, EMR and workflow can be escalated, addressed and managed by the IT and workflow consultants who are assigned at the medical center. A significant aspect of the sustainability plan involves the engagement and empowerment of the front line staff. The staff is given the appropriate education and training along with the assurance of a network of support for the success of the project. The success of the project relies heavily on participation of members of the interprofessional team. The complexity of care involved with oncology patients requires several conversations and interactions with different members of the interprofessional team over a period of time. It is critical that all members of the team know of the importance of ACP and the role they play to keep the messaging and care consistent for the patients. A SWOT analysis was conducted as part of the organizational assessment. The SWOT analysis is attached in the proposal (as Appendix D).
The EBP project involved changes at several points in the system. At the macro level, the EBP project required a change in the culture and mindset on the role everyone could play in improving rates of completion of advance directives. Completion of advance directives should now be considered an interprofessional team goal instead of just that of the physicians. At the department level (meso), the change involved how the staff incorporates ACP into their interactions with oncology patients. The change also involved staff getting comfortable with having these type of conversations while still referring the patients to their physicians for any specific questions related to prognosis and treatment. Changes at the micro level involved the using the EMR section for ACP and a documentation template.

Implementation Plan with Timeline and Budget
The vision of the project was to increase the percentage of documentation of advance directives among adult oncology patients in the clinic by incorporating ACP into current patient interactions. The long term goal for the project was this: At the end of four weeks, the percentage of adult oncology patients seen in the clinic with advance directives in their EMR would increase by 50% from baseline. Short term goals are reflected as milestones in the project's timeline (Appendix E). The objectives of the project were: 1) staff review of patients' EMR for advance directives, 2) incorporation of the ACP process into patient interactions, and 3) documentation of the process into the EMR using a template.

Project Details and Kotter's Model
The details of the project were outlined to align with each step of the Kotter's model. The initial step involved a presentation of the project that outlined the problem and the recommendations from the evidence. The presentation included baseline information on percentage of oncology patients with no documented advance directives in their EMR. The goal of the initial presentation was to get leadership approval and stakeholder buy-in to move forward with the project. The representatives from the stakeholders present during the proposal pitch verbalized their support and approved to move forward with the plan.
After the leadership approval, the approval from the Institutional Review Board (IRB) was sought and team members from stakeholder groups were identified. Once members from the stakeholder groups were identified, the important next step was to bring them together to engage them in the process and implementation itself. It is at this stage of the change process that stakeholder roles were clarified. The team developed a project charter that included the overall project's vision, scope, long and short-term objectives, and the workflow for the proposed change. The staff implementing the EBP project were educated on why the current practice needed to change and how the EBP changes needed to occur. An outline of the presentation to the staff is included as Appendix F.
Potential barriers to the project were identified; these included time and financial constraints, sudden changes in organizational priorities such as natural disasters, and leadership or staff changes. Regular communication with the nurses through weekly touch points provided information on any barriers and also monitor the project's progress. The same meetings were the forum to evaluate process measures, discuss any key learnings and celebrate any short-term wins. Real-time feedback to the nurses especially during the initial stages of the change was provided to ensure the acceleration of the right practices while clarifying any confusion. Real time-feedback also provided an avenue to celebrate wins and keep the project momentum going.
After four weeks, the data collected was organized and analyzed to draw the overall project evaluation. The data was reviewed and compared to that at baseline. The information will then be presented to the stakeholders for their feedback and continued support. It is during this time that a handoff process is started between the project manager and the identified lead who will continue to oversee the process.

Interprofessional Team
The success of the project lies in ensuring that there is representation of thought from different members of the interprofessional team. The project manager involved people from several disciplines and professions beginning at the stakeholder conversations to the weekly meetings. The members of the interprofessional team included leaders from the department and the medical center, the providers in the department, the staff incorporating the ACP conversations in their patient interactions, the regional consultant, and the other clinic staff such as medical assistants (MAs) and licensed vocational nurses (LVNs).

Resources
The goal for the project was to keep it budget neutral. Table 1 outlines how the project implementation may have financial impact specifically to human resources. Time that the team dedicated to the project was associated with dollar amount of salary and benefits. However, it was not expected for this time to be over and beyond what is normally expected of the team. The student assumed the project manager role during the implementation so there was no associated cost to the department. The change in the practice involved the incorporation of the ACP conversation into existing interactions or visits the RN has with the patient. The addition was not expected to significantly impact the RNs time to warrant overtime pay. With stakeholder support, the time spent by the consultant, educator, informatician and quality coordinator was assumed available towards the project's success.

Project Management
Project management was assumed by the student involved in the EBP change. A local leader has been identified for the sustainability of the project.

Results
The EBP project proposal was sent to USAHS EPRC committee for approval. The approved project proposal was then submitted to the organization's IRB for an expedited review.
The support from the practicum site was secured from the CNO of the practicum site after IRB approval.
The project was conducted at the outpatient Oncology clinic of the practicum site over four weeks. Participants of the project were adult patients 18 years and over who did not have advance directives or POLST documented in their EMR. Therefore, patients with documented advance directives or POLST were not be included in the project. The EBP change involved the staff incorporating the ACP process into the interactions with patients who met the criteria. The data was captured directly into the patients EMR. The project manager did not require access to patient information nor store data separately thereby maintaining confidentiality throughout the project.
The project's outcome measure was the percentage of patients with documentation of completed advance directives. The project utilized data that was already being collected by the quality and analytics department. The analysts who previously performed the data abstraction from the EMR were able to support the project while maintaining their routine processes.
Baseline data of the percentage of adult oncology patients with documented advance directives or POLST was gathered from the EMR data sets prior to implementation.

Data Analysis
Prior to the project implementation, 905 out of the 3,971 patients had documented advance directives or POLST. At the end of the implementation, there were 882 out of 4,122 oncology patients with completed advance directives or POLST; this was a decrease from the pre-implementation data. Using the unpaired t-test at the p value of < 0.05, the difference between the pre-and post-implementation data is not statistically significant (see Table 2 and 3).
Further analysis was performed to identify possible factors that affected the data. One thing to note is the increase in the population of patients from the previous month; this increase perhaps Aside from the overall outcome, the project manager utilized process, balancing, financial, and sustainability measures. During the project implementation, the process measure showed that the staff incorporated the ACP process into their patient interactions 124 times.
Financial measure did not show overtime hours nor overtime pay incurred by the staff associated with the EBP change. Sustainability measure would involve monitoring the percentage of patients with completed advance directives or POLST every month after initial intervention. Table 4 in the Appendix provides details at a glance on how these measures were retrieved and when.

Clinical Significance
Perhaps the most important outcome from the project was in its clinical significance to both nursing practice and patient outcomes. This project highlighted the important role of nurses in ambulatory care in patient advocacy. This in-turn also showed how nurses affect metrics associated with quality outcomes. The staff who participated verbalized an understanding on how important their role was not just in addressing current needs but also in helping the patients be actively involved in planning for their future. The staff verbalized how supported they felt about having an interprofessional team to refer the patient for questions that might need further explanation or conversation.
Ultimately, the clinical significance of the project was in helping oncology patients understand the importance of identifying their wishes and making them known to their family and their healthcare team. A documented advance directive is a way that the patients maintain control over their health and bodies at a time where most events occur without it (Epstein et al., 2019). Although the data does not reflect an associated increase in completed advance directives, the interactions with ACP process provided the patients the resources they need to make their wishes known and take control of their care.

Impact
The EBP project aimed to address the problem of having low percentage of oncology The change in practice can be sustained with consistent messaging on why having documented advance directives is important and how staff contribute to its completion. The leaders and stakeholders appreciate the importance of the EBP change as a key component of oncology care. They agree that practice should continue with no need for additional funding. The project will be sustained using the same steps of the ACP process and documentation template.
The data on how often the staff are using the EMR to document the ACP process will continue to be monitored. This data will be used to provide feedback to the staff and how the practice can be consistently adopted into their workflows. The data on the percentage of oncology patients complete advance directives after the ACP process will also be monitored. Ongoing evaluation of measures, staff feedback, and communication will be continued by an identified lead at the local medical center as well as a regional consultant.

Limitations
Several factors affect the documentation of advance directives in the EMR (Bestvina & Polite, 2017;Turley et al., 2016). Neubauer et al. (2015) further posited that increasing documentation of advance directives in the EMR is challenging for multiple reasons. There were several factors that influenced the results of the project. The project timeline was shortened because of changes in operational priorities at the time. Four weeks may not have been enough for patients who did receive the ACP intervention to turn in their completed advance directive or POLST to be uploaded into their EMR. The project was also implemented during a time when the department was severely impacted with staffing shortages in contrast to the increased volume of patients. These perhaps affected how often the staff were able to incorporate the ACP process into their interactions.

Dissemination
Dissemination of any outcomes from the change project is a key component of EBP . The dissemination is intended to provide the department with the results from the project implementation, reinforce the need to sustain the project, share the experience with peers, and enhance the learning experience of other DNP leaders.
The results of the project were shared with the stakeholder group through virtual meeting platform. The audience included the CNO, the managers of the department, and a few of the staff. The person who was identified to sustain the EBP project was also in attendance. This presentation included the data from the identified process and overall outcomes. The clinical significance of the project as it related to nursing practice and patient outcomes were highlighted during this presentation. This was a critical aspect of the dissemination in order to reinforce the need for sustainability.
The information related to the EBP project will be shared with peers and colleagues through poster presentation and publication. The poster presentation will focus on the results of the ACP process implementation as well as the EBP process itself. The manuscript will be submitted to the American Academy of Ambulatory Care Nursing (AAACN) for possible publication on ViewPoint. Finally, the completed EBP project manuscript will be submitted to USA's SOAR for open access.

Conclusion
The documentation of advance directives of adult oncology patients is a critical component of ensuring the quality of care they receive (Epstein et al., 2019). The intention of this project was to use EBP processes to increase the percentage of patients with completed advance directives reflected in their EMR. ACP is a key component of quality care for oncology patients and will soon be used in value-based payment programs (Levit et al., 2013;Narang et al., 2015;Peppercorn et al., 2011). ACP has also been shown to increase documentation of advance directives (Hoverman et al., 2017;Neubauer et al., 2015;Obel et al., 2014;Paladino et al., 2019;Temel et al., 2013;Tung et al., 2011;Turley et al., 2016). The implementation of a formal ACP process into current practice that leverages the EMR and other members of the healthcare team was recommended to provide the necessary structure to achieve the intended outcomes. Clinical outcomes that improved the care the oncology patients experienced from this project may not be statistically significant but are nonetheless important.
The EBP implementation would require system changes to be successful; the use of a change model such as that of Kotter's can provide guidance so these changes could be achieved.
Stakeholder support is not just important to ensure the project is implemented successfully, but is also critical for efforts to sustain improvement (Kotter, 2020). It is also worth noting that a change project that is based on the best available evidence not only improves patient outcomes but also validates the role of nurse leaders in translating research into clinical practice (Melnyk & Fineout-Overholt, 2019).

STRENGTHS
--EBP project has strong leadership support from physician, nursing and other administrative leaders --Strong interprofessional collaboration within the medical center across the continuum --Mature EMR makes it easier to implement alerts, documentation templates and centralized location for any proposed changes --Successful ACP practice in nephrology gives the local leadership some successful practices from which to draw --Passionate and experienced staff who are not only clinically competent but also familiar with the workflows involving the EMR process means that the change will not be such a significant impact to operations

WEAKNESSES
--Volume of patients seen in the clinic in relation to staff may limit bandwidth and capacity to just performing required procedure --Recent changes to department leadership can slow down the project as the new leaders are still learning their new roles --Competing operational priorities such as the increase in demand for in-person services may lessen the resources provided to the project OPPORTUNITIES --The organization is one of several service areas in the region; a few of the service areas have successful practices that can be shared and leveraged --Regional project support and oversight means that the local administration can utilize tools such as training materials, metrics and reports for this project --The Oncology Care Model (OCM) value-based payment model can provide the organization with incentives for successful implementation of ACP

THREATS
--Several competitors have established ACP practices and are meeting the elements of the OCM; patients may choose to seek care from one of these areas --There are other regulations involved with OCM that would need to be addressed beyond ACP implementation NUR7801 NUR7802 NUR7803

Activity
Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15  Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15  Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 and various peer groups Disseminate findings to practice community x  Note: Using unpaired t-test at the p value of < 0.05, the difference between the pre-and postimplementation data is not statistically significant.