knowledge translation: practical strategies for success v1
DESCRIPTION
A stepwise practical guide for successfully completing a Knowledge Translation intervention.TRANSCRIPT
Knowledge TranslationMoving from Best Evidence
to Best Practice
Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBS
Consultant Physician & Pulmonologist
Chairman, Knowledge Translation Committee
Department of Medicine
KAMC
Riyadh
Kingdom of Saudi Arabia
Q: What Scares
Doctors?
Patients
Colleagues
AdministrationA: Being Patients
Time cover story - May 1, 2006
Q: What Scares Doctors?
A: Being the Patient
Updated September 21, 2012, 10:56 p.m. ETHow to Stop Hospitals From Killing Us????Medical errors kill enough people to fill four jumbo jets a week
Stop making mistakes…STOP WORKING!
Quality Chasm
• 439 indicators of clinical quality of care
• 30 acute and chronic conditions, plus prevention
• Medical records for 6712 patients
• Participants had received 54.9% of scientifically indicated care (Acute: 53.5%; Chronic: 56.1%; Preventive: 54.9%)
McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-264 .
Conclusion: The “Defect Rate” in the technical quality of American health care is approximately
45%!!!!!!!
“Crossing the Quality Chasm”
Institute Of Medicine 2001
• Under use – helpful services not delivered
• Overuse – useless interventions
• Mistakes – inevitable human error
Crossing the Quality Chasm: A New Health System for the 21st Century, available at: http://www.nap.edu/books/0309072808/html/
Other “Failure Modes in KT”
Folic acid supplements pre-pregnancy Promoting and supporting breast feeding Promoting use of preventers in chronic
asthma Achieving blood pressure control Optimizing care for stroke patients Preventing osteoporosis related fractures re-
occuring
What is KT & why
is it importan
t?
How to Do It? A Framework for KT.
Practical Example.
Many terms, same basic idea …
1. Applied health research2. Diffusion3. Dissemination 4. Getting knowledge into
practice5. Impact6. Implementation 7. Knowledge communication8. Knowledge cycle9. Knowledge exchange 10. Knowledge management11. Knowledge translation
12. Knowledge to action13. Knowledge mobilization 14. Knowledge transfer 15. Linkage and exchange16. Participatory research17. Research into practice18. Research transfer19. Research translation 20. Transmission 21. Utilization
What is Knowledge Translation?
Knowledge Translation is about: Making users aware of knowledge and facilitating
its use to improve health and health care systems Closing the gap between what we know and what
we do (reducing the know-do gap) Moving knowledge into action
Knowledge Translation research (KT Science) is about:
Studying the determinants of knowledge use and effective methods of promoting the uptake of knowledge
BE M
E to P
Bridging the Gaps
Knowledge Practice
Resources Expenditure
Current State of Knowledge Translation
“health care systems globally have failed to timely, consistently and comprehensively apply new knowledge at both the macro and micro levels of care”1,2,3.4
McGlynn E, Asch S, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med 2003;348:2635-45.
Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care 2001; 39:II46-II54.
Shah BR, Mamdani M, Jaakkimainen L, Hux JE. Risk modification for diabetic patients. Are other risk factors treated as diligently as glycemia? Can J Clin Pharmacol 2004;11(2):e239-e244.
Kennedy J, Quan H, Ghali WA, Feasby TE. Variations in rates of appropriate and inappropriate carotid endarterectomy for stroke prevention in 4 Canadian provinces. CMAJ 2004; 171(5):455-459.
Bridging the Implementation Gap
Implementation Gap
Scientific understanding
Patient care
Prog
ress
Time
Current State of Knowledge Translation
“Bridging this so called Knowledge-to-Action gap has been extremely slow sometimes taking years following the availability of new knowledge”
Paul Glasziou and Brian Haynes. The paths from research to improved health Outcomes. Evidence-Based Medicine 2005; 10:4-7.
Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70
Knowledge Application (Action Cycle) includes:
1
•Identify the problem
2
•Measure Magnitude and Determine the Root-Cause
3
•Pass to your KT Team
4
•Find (& Appraise) the Evidence
5
•Assess barriers and facilitators to knowledge use.
6
•Adapt knowledge to local context
7
•Select and implementing interventions
8
•Monitor knowledge use: Process & Outcome
9
•Sustain knowledge use
Step 1: Identifying the problem- Identify the Knowledge-To-Action Gap
Resources: Gap or Error Detection
• Organization level:• Health records• Chart audits e.g. M&M reports
• Provider level:• Direct observation• Questionnaires
• Patient Level:• Patient Complaints• Questionnaires
Skills for Problem Detection
• Process Change Skills
Step 2: Identify the Magnitude of the Problem- (for future comparison post-intervention) & Its Root-Cause
Resources: Gap or Error Detection
• Organization level:• Health records• Chart audits e.g. M&M reports
• Provider level:• Direct observation• Questionnaires
• Patient Level:• Patient Complaints• Questionnaires
Skills/Tools for Root Cause Analysis/Detection
• Process Change Skills• Check Sheet• Cause-and-Effect Diagram• Flow Charting• Pareto Chart• Scatter Diagram• Probability Plot• Histogram• Control Charts• Brainstorming• 5 Whys Tool
Step 3: Pass to your KT Team
Composition of A KT Team
• Multidisciplinary• Clinicians• Pharmacists• Nursing• Trainees• Quality Mgt staff• Monitors • Statistician• Librarian (EBM)• Patient Representative
Skills/Tools for Team Work
• Process Change Skills• Roles:
• System leadership• Technical leadership• Day-to-day leadership
Step 4: Find the Evidence: Searching & Appraising Evidence
Resources: EBM Resources
• AHRQ Agency for Healthcare Research and Quality http://www.ahrq.gov/
• NICE National Institute for Health and Clinical Excellence: www.nice.org.uk
• Guidelines Clearinghouse: http://www.guideline.gov/
Skills for EBM Practice
• EBM Skills• Ask• Acquire• Appraise
Step 5: Find the Barriers- Assess Barriers to Knowledge Use
Barriers to Change
• Organizational (Structure: equipment & Process: time)
• Individual• Knowledge• Attitude• Skills• Social (acceptability by
society & patients)
Skills for Management of Change
• Process Change Skills
Step 6: Adaptation Phase- Adapt Knowledge to Local Context (Adaptability)
Barriers to Use
• Adequate resources:
• Manpower• Economic/Financial• Leadership• Political• Etc.
Skills for Adaptation
• Process Change Skills• EBM Skills (The ADAPT
Tool)
Step 7: Find the Tools- Select, Tailor & Implement Interventions
Tools for Implementation
• Organization directed:• Legislation/Leadership
Commitment• Policies & Procedures -Reminder
Systems: Clinical Pathways, Order Sets, Check-lists
• System Redesign• Individual directed• Training Program• Certification• Patient directed :• Education, Partnership
agreements etc
Skills for Successful Implementation
• Process Change Skills• EBM Skills: Apply-
EBM Implementation Tools
• System Redesign
Hierarchy of Evidence-Based Implementation Tools
Consistently effective interventions • Educational outreach visits • Reminders (manual or
computerized) • Multifaceted interventions* • Interactive educational
meetings (workshops)• Financial Incentives
Interventions that have little or no effect • Educational materials (Printed practice guidelines,
audiovisual materials, and electronic publications) • Didactic educational meetings (such as lectures)
Interventions of variable effectiveness • Audit and
feedback • Use of local
opinion leaders • Local consensus
processes (ownership)
• Patient mediated interventions
The Implementation Pyramid
* (a combination that includes two or more of the following: audit and feedback, reminders, local consensus processes, or marketing)
What is System Redesign?
System redesign is a new concept in healthcare reform.
It entails specific redesign in care delivery both in its structure and in its process in order to re-align a faulty system and improve outcomes.
The whole structure or process of care is redesigned to an “ideal process” based on evidence.
Structure• New Division e.g. KT Division• New Team e.g. Anticoagulation
Team• Revised Job-description e.g. KT
MonitorProcess• Redesign Training Programs
• Computerized Decision Support Systems
• Electronic Orders/Pathways/Protocols and Reminders
• SBAR• Checklists
Outcome• Patient Satisfaction Surveys• Staff Satisfaction Surveys
If you do not know where you want to go……… Implementation/KT websites Quality Improvement website
1. AHRQ Agency for Healthcare Research and Quality http://www.ahrq.gov/2. NICE National Institute for Health and Clinical Excellence: www.nice.org.uk3. Clinical Improvement Skills: http://www.improvementskills.org/index.cfm4. Institute for Healthcare Improvement:
http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/5. Knowledge Translation Clearinghouse: http://ktclearinghouse.ca/6. ICSI Institute for Clinical Systems Improvements
http://www.icsi.org/index.aspx7. Society of Hospital Medicine: http://www.hospitalmedicine.org/8. Innovations Exchange for New Ideas of Care http://innovations.ahrq.gov/
Step 8a: Monitor the Change- Monitor Knowledge Use (The Process)
Tools for Monitoring the
Process
• Process Variance (Audit)
• Knowledge use by providers:
• Knowledge use by patients:
Skills for MonitoringImplementati
on
• Process Change Skills
Step 8b: Monitor the Change- Monitor Knowledge Use (The Outcome)
Tools for Monitoring the
Process
• Outcome Variance (Audit)
• Impact on:• Patients• Providers• Organization
Skills for Monitoring
Implementation
• Process Change Skills
Step 9: Sustain the Improvement
Tools for Encouraging Compliance
• Regular Audit• Regular Update• Incentives• Competency-based
Training• Certification:
Individual & Organizational
Skills for Sustaining Change
• Process Change Skills
The necessary building blocks for successful KT based on the above:
Process Change skills EBM Skills Implementation of Change Tools System Redesign Skills KT Competency/Competency-Based Training
Curricula
The Five-Component Model for a Successful Knowledge Translation Undertaking
How Can I Do It???
KT of a Classic PT Case: Can it be Done?
Documentation o f Red Flags in referrals to PT with Low Back Pain
Red flags are warning signs that suggest that physician referral may be warranted.
LBP Red Flags
Thoracic pain Widespread neurological deficit Lower limb weakness Drug abuse/human
immunodeficiency virus Age <20 or >55 years Weight loss Persistent severe restriction of
lumbar flexion Constant progressive, non-
mechanical pain Night pain Positive cough/sneeze Previous history of cancer Recent history of trauma
Cauda equina symptoms Altered bladder control Saddle anesthesia Altered bowel control Widespread neurological
deficit
Documentation of RED Flags in LBP Referrals to PT: POOR KT!
USA Saddle Anesthesia 19% of Cases Night Pain 68% LL Neurodeficits 19% Bladder Dysfunction 13.8%
UK Scotland 33%
Leerar PJ, BoissonnauttW, Domholdt E, Roddey T. Documentation of red flags by physical therapists for patients with low back pain. J Man Manipul Ther 2007;15:42–9.
Ferguson F, Holdsworth L, Rafferty D. Physiotherapy. Low back pain and physiotherapy use of red flags: the evidence from Scotland. 2010 ;96(4):282-8.
Physical Therapists’ Use of Interventions With High Evidence of Effectiveness in the Management of aHypothetical Typical Patient With Acute Low Back Pain
Results. Use of interventions with strong
or moderate evidence of effectiveness: 68%. Use interventions for which research evidence
was limited or absent.90%
Physical Therapists’ Use of Interventions With High Evidence of Effectiveness in the Management of aHypothetical Typical Patient With Acute Low Back Pain
Discussion and Conclusion. Although most (not really!) therapists use
interventions with high evidence of effectiveness, much of their patient time is spent on interventions that
are not well reported in the literature.
Christine Mikhail et al. Physical Therapy . Volume 85 . Number 11 . November 2005
Knowledge Application (Action Cycle) includes:
1
•Identifying the problem (Audit of Low Back Pain LBP care)
2
•Measure Magnitude and Determine the Root-Cause
3
•Pass to your KT Team
4
•Find (& Appraise) the Evidence
5
•Assess barriers and facilitators to knowledge use.
6
•Adapting knowledge to local context
7
•Selecting and implementing interventions (TOOLS)
8
•Monitoring knowledge use: Process & Outcome (LBP Monitor)
9
•Sustaining knowledge use: Re-audit, Update, Certify/Accredit
An Audit Cycle
KT for LBP: Implementation Tools
•Education, Back Pain Clinical Pathway, Checklists
Implementation Tools
•LBP Team, LBP Monitor,
•Electronic H&P, Order Set
System Redesign
Examples of Clinical Pathways
KT in Summary
Getting research into practice
Is a Complex but Achievable Task
Collective Effort
Organizational and Individual Responsibilities
Patient Right
BE M
Lessons from experienced guideline implementers: Attend to many factors and use multiple strategies. Journal of Quality Improvement 2000; 26(4):171-188.
Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1998;317:465-468.
Evidence-based implementation of evidence-based medicine. Jt Comm J Qual Improv. 1999;25(10):503-13.
Translating guidelines into practice: A systematic review of theoretical concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CAN MED ASSOC J, 1997; 157 (4)409-416.
A guide to the development, implementation and evaluation of clinical practice guidelines. National Health and Medical Research Council. Commonwealth of Australia 1999.
Integrated care pathways. BMJ 1998;316:133-137.Using checklists and reminders in clinical pathways to improve
hospital inpatient care. MJA 2004; 181 (8): 428-431.
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