Knowledge translation model, tools and strategies for success

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Knowledge Translation: Tools for Success

Knowledge Translation: Tools for Success

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  • 1. Knowledge Translation Moving from Best Evidence to Best Practice Dr. Imad Salah Ahmed Hassan MD FACP FRCPI MSc MBBS Consultant Physician & Pulmonologist Chairman, Knowledge Translation Committee Department of Medicine KAMC Riyadh Kingdom of Saudi Arabia imadsahassan@gmail.com
  • 2. 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%) Conclusion: The “Defect Rate” in the technical quality of American health care is approximately 45%!!!!!!! McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-264 .
  • 3. “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/
  • 4. 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 reoccuring
  • 5. Steps What is KT? How to Practice KT? Where Do I Go From Here?
  • 6. Objectives  To define & understand knowledge translation  To appreciate why KT is important  To provide a framework for knowledge translation
  • 7. Many terms, same basic idea … 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Applied health research Diffusion Dissemination Getting knowledge into practice Impact Implementation Knowledge communication Knowledge cycle Knowledge exchange Knowledge management Knowledge translation 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Knowledge to action Knowledge mobilization Knowledge transfer Linkage and exchange Participatory research Research into practice Research transfer Research translation Transmission Utilization
  • 8. 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
  • 9. E E to B M P Bridging the Gaps  Knowledge Practice  Resources Expenditure
  • 10. 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:II46II54. 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.
  • 11. Progress Bridging the Implementation Gap Scientific understanding Implementation Gap Patient care Time
  • 12. 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; 6570
  • 13. Basic Concepts in KT  Concept  No.: 1 “a set or series of interconnected or interdependent parts or entities that act together in a common purpose or produce results impossible by action of one alone”.
  • 14. Health Care Model: Donabedian Model Anatomy Care Process Structure Process •Staff •Departments •Equipment •Supplies •Environment Outcome •Pathways •Protocols •Physician orders •Nursing Care •Housekeeping •Transport Six Ds: Death Disease Disability Discomfort Dissatisfaction Destitution (cost)
  • 15. Basic Concepts in KT  Concept    No.: 2 Organizational Structure Professional (Knowledge, Skill or Attitude barriers) Social
  • 16. Barriers to KT: Need to be Addressed at the Outset Organisational Barriers Professional Social  Non-committed leadership  Lack of EBM knowledge and skills  Lack of time  Lack of or no access to information sources  Not applicable to individual patient  Pharmaceutical industry have influence on evidence  Organizational Chaos  Experience not taken into account  Patient preferences must be respected  Lack of Mechanisms to Monitor care Delivery  Erosion of autonomy  No financial profits
  • 17. Basic Concepts in KT Concept No.: 3
  • 18. Knowledge Attitude Skills "Fit for purpose“ "Right first time" The Close Inter-relationship and Dynamics between Staff-Competency, Quality of Care and Knowledge Translation: Competency drives Quality which in turn leads to better Knowledge Translation
  • 19. The SIX Domains of Quality Care
  • 20. The Five Essential Components for Successful KT in Healthcare Systems   KT is primarily a concept for bringing up change. This change should be:    Evidence-based be successfully Implemented using the right tools employing established Process Change Skills and strategies.
  • 21. The First Three Prerequisites Scientifically proven knowledge, based on the science of Evidence-based Medicine Scientifically proven successful Implementation of Change Tools Scientifically proven Process Change Actions
  • 22. The Five Essential Components for Successful KT in Healthcare Systems  KT is primarily a concept for bringing up change. As per the Institute for Healthcare Improvement, any effort to improve the quality of patient care must incorporate another new concept namely System Redesign The fourth essential components for a KT undertaking is System Redesign.
  • 23. 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.
  • 24. The Five Essential Components for Successful KT in Healthcare Systems    KT is primarily a concept for bringing up change. The fifth vital component pertains to the new knowledge and skills that healthcare staff have to attain to fulfill the above 4 elements. These new competencies entail a redesign of staff training curricula with emphasis on KT competency as a new and extremely essential skill.
  • 25. The Five-Component Model for a Successful Knowledge Translation Undertaking
  • 26. The Five-Component Model for a Successful Knowledge Translation Endeavour EBM Implementation of Change Tools KT System Redesign Process Change Skills KT Competency Training
  • 27. Evidence-based Practice Ask clinical Acquire the questions best evidence Assess 5A’s !! Appraise effectiveness, efficiency of EBM process the evidence Apply evidence to Your patient
  • 28. Acquire the Best Evidence The Sources of Evidence Pyramid Pre-appraised, systematic reviews: Cochrane, DARE, Clinical Evidence, EPC Evidence Reports (in AHRQ) Pre-appraised, individual studies: InfoPOEMs, ACP Journal Club Databases with EBM, background, and guideline info.: InfoRetriever®, DynaMed®, ACP’s PIER, Guideline Clearinghouse and USPSTF (in AHRQ), NICE Highly referenced, current e-textbook: Upto-Date, Scientific American Standard e-textbooks, PDA e-textbook (5MCC) PubMed (Clinical Queries), Medline *Adapted from Shaughnessy and Slawson
  • 29. If you do not know where you want to go………   Implementation/KT websites Quality Improvement website AHRQ Agency for Healthcare Research and Quality http://www.ahrq.gov/ NICE National Institute for Health and Clinical Excellence: www.nice.org.uk Clinical Improvement Skills: http://www.improvementskills.org/index.cfm Institute for Healthcare Improvement: http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/ Knowledge Translation Clearinghouse: http://ktclearinghouse.ca/ ICSI Institute for Clinical Systems Improvements http://www.icsi.org/index.aspx Health Care Improvement Skills Centre: http://improvementskills.org/  Society of Hospital Medicine: http://www.hospitalmedicine.org/
  • 30. It is vitally important to note that both individual and organizational factors need to be addressed for successful implementation to take place.
  • 31. Hierarchy of Evidence-Based Implementation Tools The Implementation Pyramid Interventions of variable effectiveness •Audit and feedback •Use of local opinion leaders •Local consensus processes (ownership) •Patient mediated interventions 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) * (a combination that includes two or more of the following: audit and feedback, reminders, local consensus processes, or marketing)
  • 32. Barriers for Knowledge Translation Organisational Barriers Professional Social  Non-committed leadership  Lack of EBM knowledge and skills  Lack of time  Lack of or no access to information sources  Not applicable to individual patient  Pharmaceutical industry have influence on evidence  Organizational Chaos  Experience not taken into account  Patient preferences must be respected  Lack of Mechanisms to Monitor care Delivery  Erosion of autonomy  No financial profits  Evidence hard to implement  Lack of skills in knowledge management
  • 33. Organisational Interventions: STRUCTURES Unyielding leadership/regulatory body’s support both materially and in manpower. Specialized/KT Clinical Teams & Divisions Multidisciplinary teams: Stroke Team, Diabetes team, Heart Failure Team etc Revision of professional roles e.g. increased clinical roles to nurses and expanding the roles of pharmacists Compulsory KT/EBM rotation/certification/ CME hours during training.
  • 34. Organisational Interventions Access to medical information: Telephone Hotline, Intranet and Internet access , Well-stocked Medical Library , Personal Digital Assistant/Pocket PCs etc. Educational materials: Memos, letters, electronic reminders (emails, discussion groups, internet sites/links) Education /Postgraduate Training Department. Quality Improvement Committees incorporating KT principles Clinical Audit /Audit Department, Mortality and Morbidity Review. Regular assessment/feedback from endusers and health consumers e.g. questionnaires, self-report activities etc.
  • 35. Organisational Interventions Patient-and Patient-Group mediated Interventions* “Patient Values & Preferences” Patient Education Department. Methods of Educating Patients/SelfManagement Verbal (by doctor, nurse or trained educationalist). Written (leaflets, booklets, posters). Audio tapes. Video tapes (for loan, or playing in waiting rooms etc.) Public lectures. Support group meetings. Newspaper/magazine articles/Internet. Drama.
  • 36. Professional Interventions: PROCESS Knowledge Attitude Skills
  • 37. Professional Interventions Knowledge • Educational • Workshops on KT: EBM, Process Change, System Redesign, Competency, Implementation Tools. • Lectures by senior figures, leaders, experts on improvement topics etc.
  • 38. Professional Interventions Attitude • Involving important and committed individuals from all relevant disciplines. • Involving and informing all parties (Stakeholders). • Implementation tool must be built into daily patients’ care. • Implementation should take place at the point of time with clinical decisionsupport tools and real time disease and patient specific reminders. • Linking interventions to needs. • Needs Survey • Incentives • • • • • • • Reduction in clinician’s workload. Financial. Conference/Travel reimbursements. Recognition/Accreditation Certificates. Endorsement by International Bodies. Divisional/Institutional League Tables. Protection against Litigation.
  • 39. Professional Interventions Skills • Decision Support Tools: computerized reminders, reminders incorporated in clinicians’ daily work e.g. in Clinical Pathways and Protocols, Order Sets, Check-lists etc. • Clinical KT Enhancing Tools: • Morning Meeting • Ward Round • Journal Club • M&M Reviews Presentations • Audit Presentations • Competency Training • KT Research
  • 40. Model for Improvement
  • 41. Topic Review/ Update Team Monitor Objectives Process Change Skills Implement Awareness EBM Brainstorming Pilot Produce b
  • 42. Knowledge Application Knowledge application (action cycle) includes: 1. 2. 3. 4. 5. 6. 7. Identifying the problem Adapting knowledge to local context Assessing barriers and facilitators to knowledge use Selecting and implementing interventions Monitoring knowledge use Evaluating outcomes; and Sustaining knowledge use.
  • 43. 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.
  • 44. 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, nonmechanical 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
  • 45. Documentation of RED Flags in LBP Referrals to PT: POOR KT!  USA     Saddle Anesthesia Night Pain LL Neurodeficits Bladder Dysfunction 19% of Cases 68% 19% 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.
  • 46. Physical Therapists’ Use of Interventions With High Evidence of Effectiveness in the Management of a Hypothetical 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%
  • 47. Physical Therapists’ Use of Interventions With High Evidence of Effectiveness in the Management of a Hypothetical 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
  • 48. KT for LBP: Actions Process Change EBM Implementation Tools System Redesign Competency Training • Skills for Management of Change • Education & Training • Education, Back Pain Clinical Pathway, Checklists • LBP Team, LBP Monitor, Electronic H&P, Order Set • EBM, Implementation Tools Development, Process Change, System redesign etc
  • 49. KT in Summary Getting research into practice Is a Complex but Achievable Task Collective Effort Organizational and Individual Responsibilities Patient Right