Illustration of the Knowledge to Action Illustration of the Knowledge to Action ProcessProcess

Ian D Graham PhDCIHR

Vice President, Knowledge Translationand Public Outreach

KT Master ClassKT Master Class

CLAHRC ConferenceCLAHRC Conference

Sheffield, UKSheffield, UK

October 5October 5thth, 2010, 2010

Learning Objectives

• To better understand the knowledge to action process by going through a specific implementation project

• To be able to use a conceptual framework to think through an implementation project

Knowledge, if it does not determine action, is dead to us.

Plotinus (Roman philosopher 205AD-270AD)

Emergency instructions for those who are theory averse

MonitorMonitorKnowledgeKnowledge

UseUse

SustainSustainKnowledgeKnowledge

UseUse

EvaluateEvaluateOutcomesOutcomes

AdaptAdaptKnowledgeKnowledge

to Local Contextto Local Context

Assess Barriers/Assess Barriers/Supports to Supports to

Knowledge UseKnowledge Use

Select, Tailor,Select, Tailor,ImplementImplement

InterventionsInterventions

Identify ProblemIdentify Problem

Identify, Review,Identify, Review,Select KnowledgeSelect Knowledge

Products/Products/ToolsTools

SynthesisSynthesis

Knowledge Knowledge InquiryInquiry

Tailo

ring

Kno

wle

dge

KNOWLEDGE CREATIONKNOWLEDGE CREATION

from: Graham et al: Lost in Knowledge

Translation: Time for a Map?http://www.jcehp.com/

vol26/2601graham2006.pdf

The knowledge to action (K2A) framework

assumes a systems perspective falls within the social constructivist paradigm which

privileges social interaction and adaptation of research evidence that takes local context and culture into account

• designed to be used by a broad range of audiences • has been widely cited: 120 in ISI Web of Knowledge,

290 in H – Harzings Publish or Perish, which picks up the grey literature (as of Sept 24, 2010)

• has not, as yet, been tested empirically

The knowledge to action (K2A) framework: derivation

• the set of 31 theories on which the framework is based, can provide more specific guidance as to what needs to be done at each phase

• each theory has been broken down into its components and data abstraction sheets for each can be found at http://www.iceberg-grebeci.ohri.ca/research/kt_theories_db.html

• each of the component theories is mapped onto the K2A framework

• future iterations of the framework will be informed by feedback from the researchers and knowledge-users who are trying to apply it.

The knowledge to action (K2A) framework

More on the systems perspective. • knowledge producers and users are situated within a

social system or systems that are responsive and adaptive, although not always in predictable ways.

• the K2A process is considered iterative, dynamic, and complex, with the boundaries between the creation and action components are fluid and permeable.

• the action phases may occur sequentially or simultaneously and the knowledge phases may influence or be drawn upon during action phases.

• the cyclic nature of the process and the critical role of feedback loops are key concepts underpinning the framework

The knowledge to action (K2A) framework

• the framework encompasses research based as well as other forms of knowing such as contextual and experiential knowledge

• both the knowledge creation and action components can be “activated” by different stakeholders and groups working independently of each other at different points in time

• a key assumption underlying the framework is the importance of appropriate relationships

The knowledge to action (K2A) framework

• the action phases enable the framing of what needs to be done, how, and what circumstances/conditions need to be addressed when implementing change.

• they are not meant to replace or over ride the component theories from which the phases were derived. e.g. when addressing the barriers to knowledge use, 18 of

the 31 planned action theories had a construct dealing with this – some with more precision and coverage than others.

• for each action phase other (non-planned action) theories (psychological, organizational, economic, sociological, educational, etc) may be relevant and useful (see, for example Wensing et al., 2009 in the book)

The K2A framework: limitations in how we drew it

• our representation of the K2A cycle suggests circularity or a sequence of phases that need to be taken in order

• we realize that this is not how implementation projects unfold in “real life”.

• they are often chaotic, and move forward in an erratic manner with continuous course corrections as the action phases accommodate the contextual factors.

• a better representation of our framework would be the probabilistic atomic model, where the action phases are like electrons around the nucleus of knowledge generation - and the contextual factors influence where a given phase might be at a specific time.

=

The K2A framework: limitations in how it is represented

• the two dimensional, linear representation of the framework might seem to preclude the possibility that change can occur at multiple levels.

• there is nothing inherent about the framework that would exclude its use at multiple levels.

• Ferlie et al. confirm non-linear models of innovation spread. They argue that there is no linear flow or prescribed sequence of stages.

“Indeed, flow is a radically inappropriate image to describe what are erratic, circular or abrupt processes, which may come to a full stop or go into reverse”

Ferlie et al page 123.

Ferlie, E., Fitzgerald, L., Wood, M., & Hawkins, C. (2005). Thenonspread of innovations: The mediating role of professionals.Academy of Management Journal, 48, 117-134.

The knowledge to action (K2A) framework

• The framework has become a key part of messaging about knowledge translation at CIHR since September, 2007.

• It has been presented to a variety of CIHR’s stakeholders and internal staff, and has been well received in the sense that it is understandable and relatively simple, yet comprehensive.

• Feedback from researchers and knowledge-users suggests that it provides a useful way of thinking about knowledge translation but more importantly, by breaking the process into manageable piece, provides a structure and rationale for activities.

Knowledge to action: a personal example

• Community care of venous leg ulcers• Collaborative interdisciplinary approach• Co-PI Dr. Margaret Harrison, Queen’s University• 6 year program of research and implementation• Integrated Knowledge Translation approach

• A community-researcher alliance to improve chronic wound care

• CIHR KT Casebook, (Graham et al, 2006)• http://www.cihr-irsc.gc.ca/e/30669.html

Venous Leg Ulcers

Population with Leg Ulcers in particular:Common, costly, complexChronic, recurringDebilitating, isolating condition80% care reported to be community-based,

delivered by nurses

A Picture is Worth a 1,000 Words

MonitorMonitorKnowledgeKnowledge

UseUse

SustainSustainKnowledgeKnowledge

UseUse

EvaluateEvaluateOutcomesOutcomes

AdaptAdaptKnowledgeKnowledge

to Local Contextto Local Context

Assess Barriers/Assess Barriers/Supports to Supports to

Knowledge UseKnowledge Use

Select, Tailor,Select, Tailor,ImplementImplement

InterventionsInterventions

Identify ProblemIdentify Problem

Identify, Review,Identify, Review,Select KnowledgeSelect Knowledge

Products/Products/ToolsTools

SynthesisSynthesis

Knowledge Knowledge InquiryInquiry

Tailo

ring

Kno

wle

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KNOWLEDGE CREATIONKNOWLEDGE CREATION

• Homecare authority identified costs associated with leg ulcer care as an issue

• Formed an alliance between decision-makers, clinicians (and researchers) for planning, and to design and conduct a needs assessment

Identify Problem

Identify, Review,Select Knowledge

Products/ Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Kno

wle

dge

KNOWLEDGE CREATION

MonitorKnowledge

Use

SustainKnowledge

Use

EvaluateOutcomes

AdaptKnowledge

to Local Context

AssessBarriers to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Knowledge InquiryProducts/

Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Kno

wle

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Identifying the ProblemWorked with the health authority and nursing agencies to understand the local:• Population• Providers, scopes of practice• Practice environment• Gaps re: evidence-based practice

Conducted Preliminary Studies

Regional prevalence & profile study • Prevalence: 1.8/1000 population (> 25 years)• 3/4 were > 65 years• Majority independently mobile • 60% had 4 or more co-morbid conditions • Recurrent - 64% had a recurrent venous ulcer• Longstanding - 60% had ulcer > 6 months, 1/3 >1 year• 40% had 2 or more ulcers

Environmental scan, expenditures • Average 19 different nurses saw any one client in month• 40% received daily or twice a day visits• 4 week costing estimated 192 cases $1.26 million nursing &

supply expenditures(Harrison, et al 2001; Lorimer, et al 2003; Nemeth, et al 2003, 2004; Friedberg, et al

2002)

SynthesisProducts/

Tools

Synthesis

Knowledge Inquiry

Tailo

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Identifying the problem

•Systematic review of incidence/prevalence studies

• High level evidence for assessment and management of venous ulcers available (numerous RCTs, Cochrane Systematic Review)

• Numerous international Clinical Practice Guidelines available

Identify Problem

Identify, Review,Select Knowledge

Products/ Tools

Synthesis

Knowledge Inquiry

Tailo

ring

Kno

wle

dge

KNOWLEDGE CREATION

MonitorKnowledge

Use

SustainKnowledge

Use

EvaluateOutcomes

AdaptKnowledge

to Local Context

AssessBarriers to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

AdaptKnowledge to Local Context

1. Identify a Clinical Area to Promote Best Practice

2. Establish an Interdisciplinary Guideline

Evaluation Group

3. Establish Guideline Appraisal Process

4. Search and Retrieve Guidelines

5. Guidelines Assessmenta) Qualityb) Currencyc) Content

6. Adaptation of Guidelines for Local Use

7. External Review – Practioner and Policy Maker Feedback;

Expert Peer Review

8. Finalize Local Guideline

9. Official Endorsement and Adoption of Local

Guideline

10. Scheduled Review and Revision of Local Guideline

1. Identify a Clinical Area to Promote Best Practice

2. Establish an Interdisciplinary Guideline

Evaluation Group

3. Establish Guideline Appraisal Process

4. Search and Retrieve Guidelines

5. Guidelines Assessmenta) Qualityb) Currencyc) Content

6. Adaptation of Guidelines for Local Use

7. External Review – Practioner and Policy Maker Feedback;

Expert Peer Review

8. Finalize Local Guideline

9. Official Endorsement and Adoption of Local

Guideline

10. Scheduled Review and Revision of Local Guideline

Practice Guidelines Evaluation and Adaptation Cycle (Graham et al 1999; Graham et al 2005)

MonitorKnowledge

Use

SustainKnowledge

Use

Evaluateoutcomes

AdaptKnowledge

to Local Context

AssessBarriers to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Tailoring Knowledge

Products/

ToolsSynthesis

Knowledge Inquiry

KNOW

LEDGE CREATIO

N

Practice Guideline Evaluation and Adaptation Cycle

The framework has been used by numerous groups• Canadian Strategy for Cancer Control• Canadian Stroke Network• Canadian Stroke Strategy• Ottawa Hospital• CIHR grant

Foundational component of the international ADAPTE process

• www.adapte.org

Ottawa-Carleton CCAC Leg Ulcer Care Protocol Reference Guide

1. Assessment Clinical history, physical exam and lab testing to assess etiology and factors contributing to the leg ulcer1, 3, 4, 6, 7

Ankle Brachial Pressure Index (ABPI) to screen for arterial disease1-4, 6, 7

2.2 Arterial ABPI less than 0.5 Refer to Vascular surgeon 1-4, 6-8

2.1 Non-Venous or Mixed 1-3, 6, 7

ABPI between 0.5 and 0.8 OR

Unusual ulcer presentation OR

Presence of other disease

Refer to the appropriate specialist1

Graduated, multilayer compression bandaging for the uncomplicated ulcer. High compression (35-40 mm Hg) is more effective than low compression. 1- 7

Applied by trained practitioner 1-7

A

4.Wound Management

A

3. Management of Leg Ulcer

Measure surface area serially over time. 1-3, 6

Wash ulcer with tap water or saline 1, 2, 4, 6 Simple non-adherent dressing 1-3, 6

Acceptable to client 1

Dressing appropriate to stage of healing and amount of exudate. 4

Moist wound environment 4-7

5. If ulcer is Painful

Hydrocolloid or foam dressing 2 Pain management plan: 1, 3, 4, 6, 7

Compression, exercise, elevation and analgesia 1, 3, 4, 6, 7

A

C

6. If no sign of infection

7. If ulcer is associated with dermatitis

8. If ulcer is unhealed after 12 weeks of active treatment 9. If ulcer has healed

No routine bacteriological swab 1-3, 5, 6

Refer for patch skin testing. 1-3, 6 Avoid products that commonly cause skin sensitivity e.g. lanolin,1 topical antibiotics 1-3, 6

Repeat ABPI 1, 2, 6 Review diagnosis, management and client adherence with treatment; may require specialist referral and/or biopsy 2-4

Compression stockings (fitted) 1-3, 5, 6 Prevention of Recurrence: Client Education3, 4, 6 skin care, 1-3, 6 exercise, 1-4, 6, 7 elevation of legs 1, 2, 6, 7

B

C

C

A

2.3 Venous ABPI at least 0.8 6,7 Absence of arterial and other non-venous disease

B

B

C

A

C

A

C

C

B

C

C

A

B

C

AssessAssessBarriers/supports to Barriers/supports to

Knowledge UseKnowledge Use

Approach to barriers assessment included:

• Knowledge, attitudes and practice (KAP) surveys of nurses and physicians (barriers to the guideline)

• Practitioner/policy maker feedback on adapted care protocol (barriers to the potential adopters)

• Discussions with providers and managers (barriers in the practice environment)

(Graham, Harrison, Friedberg et al. 2001; Graham, Harrison, Shafey et al. 2003)

MonitorKnowledge

Use

SustainKnowledge

Use

Evaluateoutcomes

AdaptKnowledge

to Local Context

AssessBarriers to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Tailoring Knowledge

Products/

Tools

Synthesis

Kn

ow

ledg

e In

qu

iry

KN

OW

LED

GE

CR

EA

TIO

N

AssessAssessBarriers/supports to Barriers/supports to

Knowledge UseKnowledge Use

• Knowledge deficits about effective treatment (compression bandaging)• Lack of skills to assess for venous disease, bandage application• Lack of dopplers• Staffing system for community nursing agency• Referral system (GP->home care; nurses->specialists)• Remuneration system for nursing agencies• Positive attitudes toward care of individuals with leg ulcers•Nurses better knowledge of than others

MonitorKnowledge

Use

SustainKnowledge

Use

Evaluateoutcomes

AdaptKnowledge

to Local Context

AssessBarriers to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Tailoring Knowledge

Products/

Tools

Synthesis

Know

ledge Inquiry

KN

OW

LED

GE

CR

EA

TIO

N

Select, Tailor,Implement

Interventions

Interventions for implementation Provider levelProvider levelTraining for nurses (UK N18 course, doppler & bandaging

training)

Practice setting levelPractice setting level Redesigned service delivery for EB leg ulcer care

dedicated RN leg ulcer care team home and clinic equipment reimbursement alterations changes to process for referral to

specialists

SustainKnowledge

Use

Evaluateoutcomes

AdaptKnowledge

to Local Context

AssessBarriers to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Tailoring K

nowledge

Products/

Tools Synthesis

Knowledge Inquiry

KNOW

LEDGE CREATIO

N

MonitorKnowledge

Use

Select, Tailor,Implement

Interventions

Developed tools to facilitate use of the recommendations Protocol algorithm (knowledge

tool/adaptation/intervention) Assessment and documentation tools

SustainKnowledge

Use

Evaluateoutcomes

AdaptKnowledge

to Local Context

AssessBarriers to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Tailoring K

nowledge

Products/

Tools

Synthesis

Knowledge Inquiry

KNOW

LEDGE CREATIO

N

MonitorKnowledge

Use

MonitorKnowledge

Use

Recommendations Uptake

Parameters of EBCPG

Pre guideline adoption(n = 66)

Post Guideline adoption(n = 238)

n (%) n (%)

Identification of Ulcer Etiology

35 (53) 238 (100)

ABPI prior to initiating compression

21 (47) 227 (95)

Serial Ulcer measurement recorded

7 (11) 80(88)

Compression bandage initiated for venous ulcers

44 (66) 148 (86)

Pain Assessment Documented

10 (15) 215 (90)

MonitorKnowledge

Use

SustainKnowledge

Use

Evaluateoutcomes

AdaptKnowledge

to Local Context

AssessBarriers to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Tailoring Know

ledge

Products/ Tools

Synthesis

Knowledge Inquiry

KNOWLEDGE CREATION

Evaluate Outcomes

SustainKnowledge

Use

EvaluateOutcomes

AdaptKnowledge

to Local Context

AssessBarriers to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Tailoring Knowledge

Pro

duct

s/

Too

ls

Syn

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isK

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MonitorKnowledge

Use

Pre-post Evaluation of Outcomes (Harrison, Graham, Lorimer et. al CMAJ 2005)

• 3 month healing rate: 23% → 56%• Nursing Visits

– median 3 → 2.1/wk– daily visiting decreased from 38% → 6%

• Supply costs – Median per case: $1923 → $406

SustainKnowledge

Use

Sustainability:

• Leg ulcer service still available in Ottawa region

• Protocol was expanded to 3 other regions (still in use in 2)

• Completed RCT of home vs clinic care

• RCT completed of two compression technologies – currently being analyzed

MonitorKnowledge

Use

SustainKnowledge

Use

EvaluateOutcomes

AdaptKnowledge

to Local Context

AssessBarriers to

Knowledge Use

Select, Tailor,Implement

Interventions

Identify Problem

Identify, Review,Select Knowledge

Tailor

ing K

nowled

ge

Pro

duct

s/ T

ools

Syn

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Lessons learned from using a collaborative approach (IKT):

Moving research to practice is an iterative process of using external evidence and producing local ‘evidence’ for planning, implementing and evaluating

Successful implementation requiresstrategic alliances between researchers & health

setting (co-production of knowledge)population health principlesneeds-based planning working at both clinical and health services levels a conceptual framework

More lessons learned from using a collaborative approach (IKT):

In moving research to practice the role of the researcher is to:create & facilitate a strategic alliance and a

solutions-focused collaboration for co-production of knowledge

bring science of synthesis to practiceuse rigorous methods for each step

(organizational planning, guideline appraisal & adoption, evaluation of the implementation)

use a conceptual framework to underpin the research and KT

More lessons learned:

In moving research to practice the role of the knowledge-users (e.g. providers and policy makers) is to: Identify the problem and engage researchers in

developing the research questions Create and facilitate the strategic alliance and

solutions-focused collaboration for co-production of knowledge

Bring their practice-based knowledge and experience to bear

Apply the findings

KT: closing the gap between evidence and action

How to close the gap between evidence and action: shift attention from individual adopters to the

organizational and environmental context for change

set targets for change monitor uptake of the research and evaluate the

health and system outcomes/impact keep it simple focus on a few important targets, practical

indicators

KT: closing the gap between evidence and action

Remember KT 101: KT for what purpose? Instrumental, conceptual

knowledge use? Who is/are the intended audience(s)? What is the message? Is it clear and

unambiguous? What is the medium? To what effect?

Making a change

KT: closing the gap between evidence and action

Making a change requires systems thinking

In theory, there is no difference between theory and practice. But in practice, there is.

Yogi BerraBaseball guy

ian.graham@cihr-irsc.gc.ca

Thank you

For more information, visit our web page:http://www.cihr-irsc.gc.ca/e/29418.html http://www.cihr-irsc.gc.ca/f/29418.html