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+Evidence BasedPractice, Researchand Quality:                                                     Hedges (2006)           ...
First show of hands…                 1     I am a staff nurse                 2   I am a manager or                     di...
+    Why do I ask?-It matters to the:           Problems        Questions          you identify      you ask          Alte...
Another show of hands:Your primary focus:                    1    Generating research                    2    Using resear...
+    Think about the last innovation that you    have been involved in:                          What did the process     ...
+    Why are we here?     Compare and contrast 3 problem solving     processes: quality improvement (QI), evidence-     b...
+A Story About aProblem
+           #           CAUTIs/10Too Many   00 daysCAUTIs!                       1st quarter
+             What   is the problem?              Whatis(are) the              cause(s)?              What is the right...
+   Who is paying attention?
+Clinical ResearchEBPQI“Knowing is not enough;we must apply. Willing isnot enough; we must do.”-Goethe
+ Quality of Care in the US: 1998-2002    Overall, 54.9% of participants received              recommended care  Compariso...
Despite unprecedented advances in+biomedical knowledge and thehighest per capita health careexpenditures in the world, the...
Despite unprecedented advances in+biomedical knowledge and thehighest per capita health careexpenditures in the world, the...
+    Research Gaps,    Duplications and    Contradictions               IOM, 2008
+                                          10 Nurse-Hospital Acquired Conditions                 High cost, high volume,...
+             HabitPaying             Active feedbackAttention?             No one excused             Data driven    ...
+PayingAttention?
+    IOM Roundtable on EBM’s goal:    By the year 2020, 90 percent of clinical decisions    will be supported by accurate,...
+ IOM Roundtable on EBM Goal: By the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, an...
 “non-profit+                                    organization to                      assist patients,                   ...
+2010 AffordableCare Act             Increased emphasis on                     systematic review as a                     ...
+    ANA Social Policy Statement (2010)    “Human   responses include any     observable need, concern, condition,     ev...
+    ANA Social Policy Statement (2010)    “Nursing  actions are theoretically     derived, evidence-based, and     requi...
+    Defining Characteristics of Nursing    Practice   Human         Theory               Nursing                         ...
+    Magnet™ Recognition   InfrastructureInfrastructure                       Process                                    o...
+                       IOM                       CMS                       AHRQ                       JC             ...
+   Distinctions?
+    Clinical Research    Research   means a systematic     investigation, including research     development, testing an...
+    Key Questions    What   is the effect…    What   is the experience….    What   is the relationship….    Etc…….
+    Steps of Research Process      Gap: Identify need and      purpose        Question: researchable           Design: al...
+    Defining evidence-based nursing    practice:      “The process by which nurses make      clinical decisions using the...
+    Defining evidence-based nursing    practice:      “The process by which nurses make      clinical decisions using the...
+    Implications of the Definition                       Clinical    • Best            Expertise    • Meaning of    • Ava...
+    Best Available       • Right                   • Sources                 • Accessible                     AvailableBe...
+                  Shift  toward pluralistic,                      inclusive definitions ofThe Nature of         what evi...
+    Reconceptualizing Evidence                       From   experience                       From   acknowledged expert...
+    Key Questions in EBP?    What   works?    What is the right way to do what     works?    For   whom does it work a...
+    Essential Steps in EBP      Ask:    Problem to Question        Acquire:      Find best available        evidence     ...
+    Quality Improvement       Systematic, data-driven process that teams        use to improve systems, processes and   ...
+    Key Questions in QI     Do   you know how good you are?     Doyou know where you stand relative to the     best?   ...
+    Essential Steps in QI à la Motorola      Define:    Problem and goals        Measure: Collect data on        current ...
+    Problem-Solving
+                     What is the effect of                      nursing stop-orders vs.                      usual physi...
+                     What is the effect of                      nursing stop-orders vs.                      usual physi...
+                    Catheter days and                     incidence of CAUTIs in                     surgical patients w...
+    How did these stories compare:    Key Differences?                Research         EBP                 QIGoal        ...
+    How did these stories compare:    Key Differences?               Research             EBP                 QIIRB requi...
+                                                            Empirically driven                       Rigor varies among...
+Are there hazards when QI=RU?
+        The    Intensive      Insulin     Therapy       Story                Target: 80-110 mg/dL
+    Intensive Insulin Tx     Leuven      Trial-2001     Large RCT 1548 surg ICU pts blindly     allocated to convention...
+
+    Practice changed
+Hold on-Meta-analysis (2010)     “Tightglycemic control is associated with a     high incidence of hypoglycemia and an  ...
+ Hold on-Meta-analysis (2010) 7   RCTs pooled with 11,425 pts  IITdid not:   Reduce 28-day mortality (OR=.95 [CI, .87-...
+ Hold on-Meta-analysis (2010)   Meta-regression     revealed:    Relationship between proportion of parenteral     calo...
+                                  hwww.flickr.com/photos/areAre there hazards when QI waitson EBP?                       ...
What is the “ideal best” type of                                                            research evidence?            ...
+Back to ourstory…
+ QI effort-implementing the evidence  from SRs and using evidence-based  strategies12                                    ...
+ How has QI been studied for its  effectiveness? Researchmethods are “weak” and messy- tremendous research challenges  ...
+    Caveats     Mostof the hospital studies conducted in     university-based hospitals     Publication   bias likely  ...
+                                 “All three approaches                                   have an important, yet         ...
+                                       Embrace  broader ideas about what                                        counts a...
How about a shift inparadigm:      +          Evidence-based Quality          Improvement
Research        EBP           QI
Research        EBPQI                E-B           QI
“Reliable knowledge has to be bothscientifically and socially robust.Knowledge can no longer bedetermined by narrowly defi...
“Reliable knowledge has to be bothscientifically and socially robust.Knowledge can no longer bedetermined by narrowly defi...
+    Themes for “how”    Shift in knowledge production: from     Mode 1 to Mode 2 research paradigms     to “speed the sp...
+                        Researchers generate                                                                             ...
+                                                                Mode 2Kitson & Bisby , 2008) www.kusp.ualberta.ca/KT08doc...
+    Models are Emerging     Knowledge-to-Action                 PARIHS                                               Ev...
+                 EngagementWhat are          Transactionalcommon themes                  Nonlinearandcharacteristics  ...
+  How do you do get  evidence into  practice? Emerging Science: Knowledge Translation (KT)Knowledge translation is a dyna...
+  Beyond  Barriers:  Knowledge  Translation (KT)Knowledge translation is a dynamic and iterative processthat includes syn...
+      6 Opportunities for KT (CIHR, 2005)                                                 Publications                   ...
+    6 Opportunities for KT (CIHR as cited in    Sudsawad, 2009)    1.    Defining research questions/methods    2.    Con...
+    KT in the US    T1-bench   to clinical research    T2-clinical   research to practice
+What evidence exists tosupport getting andsustaining evidenceimplementation?
+         Strategies that work better              Reminders, cues              Educational outreach              Inter...
+            Strategies that work better         Multifaceted interventions (includes         two or more: audit and     ...
+   Strategies that may not work      Passive distribution of      educational materials      Didactic educational meeti...
+Evidence of Effectiveness ofCommon QI Efforts
+Audit and Feedback on Compliance withRecommended Practice     72 studies making 88 comparisons vs. no tx    Risk differen...
+    VA experience with A/F-Quality    Enhancement Research Initiative (QUERI)     Timely   feedback     Individual     ...
+    Other lessons learned from QUERI     Thedoing and study of implementation are     long-term investments     Signifi...
+    SR: Lean, Six Sigma, StuderGroup    Hardwiring    9 studies of Six Sigma; 9 Lean; 1 of StuderGroup     (you know the...
Tools and+  Infrastructure                Human           Technological             Contextual
+ IOM Roundtable on EBM Goal: By the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, an...
+    IOM’s goal based on:    Learning health system-evidence     generated and applied as a natural     product of the ca...
+ IOM Themes on Infrastructure:     Planning builds to future             needs                            Trained workfor...
+    Human     Facilitation     Mentors     Communities    of practice     Communication     Relationship   building ...
+                              •Transformational                               leadership    Leadership                 •C...
+                             •Clear values/beliefs                              •Values    Culture                   indi...
+                            •Internal measures                             used routinely    Evaluation               •Au...
+ Facilitation- Mentorship           Enabling others
+                               Holistic- oriented                            Enabling others    Purpose and Role        •...
+    Skills and Attributes                                      Holistic/enabling                                  •Co-cou...
+    Information Technology               POC Access
“In the 21st century, knowledge isthe key element to improvinghealth. In the same way that peopleneed clean, clear water, ...
+    Knowledge Management    Aggregate: Put all your information    sources in one place, it auto-updates and    you can s...
+    Knowledge Transfer                  http://plus.mcmaster.ca/np/Default.aspx             http://www.tropika.net/svc/sp...
Where   do you go first+         to find the best          available evidence?          How do you usually          seek...
+ Currently, EB Clinical Guidelines  in the US:                                       Highly   decentralized:            ...
+                          Recommend single entity:                                        Buildfoundation for knowing wh...
IOM’s Framework                                                  Research Studies                                         ...
+                                             What works needed for policy                                              to...
Percapita
+    Quick Action from 2008-11                          AHRQ    SR as method to                       Standardized        ...
+         Systematic reviews should:                                       Identify                                      ...
+                    “An important barrier to                      the implementation ofPatient               CPGPreferenc...
+    How do you integrate pt preferences? Examine   the source of information for  public/consumer involvement in its dev...
+ Lisa’s top picks for implementation   resources  Cochrane     Library:            Guidelines    International     Eff...
The Issue  Remains:Know-Do Gap
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Qiebp research

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Qiebp research

  1. 1. +Evidence BasedPractice, Researchand Quality: Hedges (2006) Distinctions, Synergies, and Infrastructures to Optimize Patient OutcomesClinical Fellows GraduationTCU Lisa Hopp PhD, RNSept 21, 2011 ljhopp@purduecal.edu
  2. 2. First show of hands… 1 I am a staff nurse 2 I am a manager or director 3 I am a fellow’s mentor I am an advanced 4 practice nurse 5 I am an educator or researcher 6 I am a nurse executive I am having an identity 7 crisis
  3. 3. + Why do I ask?-It matters to the: Problems Questions you identify you ask Alternative Solutions solutions you you choose generate
  4. 4. Another show of hands:Your primary focus: 1 Generating research 2 Using research 3 Using the best available evidence Improving process and 4 outcomes 5 Thinking in action, taking care of patients 6 Other?
  5. 5. + Think about the last innovation that you have been involved in: What did the process look like?  Nice and neat?  Fits and starts?  Flexible and fluid?
  6. 6. + Why are we here?  Compare and contrast 3 problem solving processes: quality improvement (QI), evidence- based practice (EBP) and clinical research  Identify synergies and dependencies among them that lead to optimal patient outcomes  Describeideal infrastructure characteristics that promote high quality patient outcomes, evidence uptake and clinical inquiry :  mentorship  leadership  organizational culture  evaluation processes
  7. 7. +A Story About aProblem
  8. 8. + # CAUTIs/10Too Many 00 daysCAUTIs! 1st quarter
  9. 9. + What is the problem? Whatis(are) the cause(s)? What is the right thing to do?Key Issues? What is the right way to do it? What is the right cost to do?
  10. 10. + Who is paying attention?
  11. 11. +Clinical ResearchEBPQI“Knowing is not enough;we must apply. Willing isnot enough; we must do.”-Goethe
  12. 12. + Quality of Care in the US: 1998-2002 Overall, 54.9% of participants received recommended care Comparison % recommend care Asch, SM, Kerr, EA, Keesey, J., et al receiving-poor quality health care? gender women: 56.6 men: 52.3 (2006). Who is at greatest risk for age <31 yrs: 57.5 >64 yrs: 52.1 NEJM, 354, 1147-56 race black: 57.6 white: 54.1 hispanic: 57.5 income >$50K: 56.6 <15K: 53.1
  13. 13. Despite unprecedented advances in+biomedical knowledge and thehighest per capita health careexpenditures in the world, thequality and outcomes of health carefor Americans vary dramaticallyacross the country. Improvedknowledge about which treatmentsand procedures are effective couldlead to less regional differences,stronger consensus on standardsand guidelines, and lower costs.RWJ commissioned IOM to: IOM: Knowing“Recommend a sustainable, What Works inreplicable approach toidentifying effective clinical Healthcare (2008) http://www.rwjf.org/pr/product.jsp?id=25351&c=EMC-CA142services” or http://www.nap.edu/catalog.php?record_id=120388
  14. 14. Despite unprecedented advances in+biomedical knowledge and thehighest per capita health careexpenditures in the world, thequality and outcomes of health carefor Americans vary dramaticallyacross the country. Improvedknowledge about which treatmentsand procedures are effective couldlead to less regional differences,stronger consensus on standardsand guidelines, and lower costs.RWJ commissioned IOM to: IOM: Knowing“Recommend a sustainable, What Works inreplicable approach toidentifying effective clinical Healthcare (2008) http://www.rwjf.org/pr/product.jsp?id=25351&c=EMC-CA142services” or http://www.nap.edu/catalog.php?record_id=120388
  15. 15. + Research Gaps, Duplications and Contradictions IOM, 2008
  16. 16. +   10 Nurse-Hospital Acquired Conditions High cost, high volume, higher payment “could reasonably and have beenPaying prevented through the application ofAttention? evidence based guidelines”
  17. 17. + HabitPaying Active feedbackAttention? No one excused Data driven Systems
  18. 18. +PayingAttention?
  19. 19. + IOM Roundtable on EBM’s goal: By the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to- date clinical information, and will reflect the best available evidence.…the development of a learning healthcare system designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider, to drive the process of discovery as a natural outgrowth of patient care, and to ensure innovation, quality, safety, and value in health care.
  20. 20. + IOM Roundtable on EBM Goal: By the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to- date clinical information, and will reflect the best available evidence.…the development of a learning healthcare system designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider, to drive the process of discovery as a natural outgrowth of patient care, and to ensure innovation, quality, safety, and value in health care.
  21. 21.  “non-profit+ organization to assist patients, clinicians, purchasers, and policy- makers in making informed health2010 Affordable decisions by carrying outCare Act research projects that provide quality, relevant evidence on how diseases,PCORI disorders, and other health conditions can effectivelyPatient-Centered and appropriately beOutcomes prevented, diagnosed, treated,Research Institute monitored, and managed.” (GAO, 2010)
  22. 22. +2010 AffordableCare Act Increased emphasis on systematic review as a method to comparePCORI effectiveness ofPatient-Centered treatmentsOutcomesResearch Institute
  23. 23. + ANA Social Policy Statement (2010) “Human responses include any observable need, concern, condition, event, or fact of interest to nurses that may be the target of evidence-based practice” (p. 10) First time that EBP is explicit in the statement that defines our social obligation to patients
  24. 24. + ANA Social Policy Statement (2010) “Nursing actions are theoretically derived, evidence-based, and require well-developed intellectual competencies” (p.11) “Assurance of safe, quality, and evidence-based practice” (p. 19)
  25. 25. + Defining Characteristics of Nursing Practice Human Theory Nursing Outcomes Responses Application Actions (effects)(Phenomena) (Science) (EBP) ANA, Social Policy Statement (2010), p. 11
  26. 26. + Magnet™ Recognition InfrastructureInfrastructure Process outcomesResearch,EBP and QI
  27. 27. +  IOM  CMS  AHRQ  JC  ANA  ANCCEBP and Quality go hand-in-hand?
  28. 28. + Distinctions?
  29. 29. + Clinical Research Research means a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge. DHHS (2008) 45 CFR 46.102(d)
  30. 30. + Key Questions What is the effect… What is the experience…. What is the relationship…. Etc…….
  31. 31. + Steps of Research Process Gap: Identify need and purpose Question: researchable Design: aligns with question and feasibility (ethics) Collect: data via methods Analyze and Report: results and implications
  32. 32. + Defining evidence-based nursing practice: “The process by which nurses make clinical decisions using the best available research evidence, their clinical expertise, and patient preferences in the context of available resources” DiCenso, Cullum and Ciliska (1998). Implementing evidence based practice: Some misconceptions. Evidence Based Nursing, 1, 38-41.
  33. 33. + Defining evidence-based nursing practice: “The process by which nurses make clinical decisions using the best available research evidence, their clinical expertise, and patient preferences in the context of available resources” DiCenso, Cullum and Ciliska (1998). Implementing evidence based practice: Some misconceptions. Evidence Based Nursing, 1, 38-41.
  34. 34. + Implications of the Definition Clinical • Best Expertise • Meaning of • Available • Criteria experiences • Externalized • Individualized Patient Evidence Preferences
  35. 35. + Best Available • Right • Sources • Accessible AvailableBest Feasible evidence • Technique • User- for the friendly question • Exhaustive • Relevant • Pre- appraised • Standard Appraisal Tools
  36. 36. + Shift toward pluralistic, inclusive definitions ofThe Nature of what evidence is, andEvidence (1996) subsequently of what evidence based practice is.. (Pearson et al, 2005)
  37. 37. + Reconceptualizing Evidence  From experience  From acknowledged experts  From learned/official bodies  From experimental research Evidence  From any rigorous research = studies knowledge  About feasibility, arising : appropriateness, meaningfulness and effectiveness
  38. 38. + Key Questions in EBP? What works? What is the right way to do what works? For whom does it work and when? What works at the right cost? Muir-Gray, 1997; Livesley & Howarth, 2007
  39. 39. + Essential Steps in EBP Ask: Problem to Question Acquire: Find best available evidence Appraise: validity and applicability of the evidence Apply: Implement in local context Assess: Evaluate the outcomes (Sackett & Haynes, 1995)
  40. 40. + Quality Improvement  Systematic, data-driven process that teams use to improve systems, processes and outcomes  Generally conducted locally though maybe organized at larger levels Newhouse, 2007  Lean methods aim to eliminate waste  Six Sigma aims to eliminate defects “Obsessed with failure”
  41. 41. + Key Questions in QI  Do you know how good you are?  Doyou know where you stand relative to the best?  Do you know where the variation exists?  Doyou know your rate of improvement over time?  Maureen Bisognano, CEO IHI
  42. 42. + Essential Steps in QI à la Motorola Define: Problem and goals Measure: Collect data on current practice Analyze: Use data to verify causes and all factors considered Improve: Create and test new solutions Control: Ensure new state persists (Koning, 2006, J Healthcare Q)
  43. 43. + Problem-Solving
  44. 44. +  What is the effect of nursing stop-orders vs. usual physician orders on reinsertion rates, catheterHow would days and incidence ofthe story go CAUTIs in uncomplicated, non-urinary surgicalif Amanda… patients with short term indwelling catheters?Conducted clinicalresearch?
  45. 45. +  What is the effect of nursing stop-orders vs. usual physician orders on reinsertion rates, catheterHow would days and incidence ofthe story go CAUTIs in uncomplicated, non-urinary surgicalif Amanda… patients with short term indwelling catheters?Was involved in anevidenceimplementationproject?
  46. 46. +  Catheter days and incidence of CAUTIs in surgical patients with short term indwellingHow would catheters are too high.the story goif Amanda…Was involved in aQI project?
  47. 47. + How did these stories compare: Key Differences? Research EBP QIGoal Grow knowledge Close gap Best patient for better pt between know outcomes, best outcomes and do for best cost, and pt outcomes regulatory complianceRelationship Generate or Synthesize, Systematicallywith confirm new translate and optimize howknowledge knowledge use knowledge to process knowledgeTime required Longest but Longer but Aim for rapid but variable variable variableDesigns Quant to qual Before-after with Before-after with process monitor process monitor
  48. 48. + How did these stories compare: Key Differences? Research EBP QIIRB required Yes Sometimes Not usuallyFlexibility Dependent upon Dependent Generally fluid design-varies upon and locally from rigid to more approach, but driven fluid generally fluidFunding Often external Usually internal, Part of usual maybe external operational fundingTime to Long term Short term Short term toImpact immediate
  49. 49. +   Empirically driven Rigor varies amongst all; risk for bias varies depending on methods, skills, etc  Context varies from artificial to realistic-emerging research methods are far more naturalisticKey Similarities  Moving knowledge into practice is a major concern  Aim to improve patient outcomes  New evidence can emerge from all 3 processes though ability to generalize varies
  50. 50. +Are there hazards when QI=RU?
  51. 51. + The Intensive Insulin Therapy Story Target: 80-110 mg/dL
  52. 52. + Intensive Insulin Tx  Leuven Trial-2001  Large RCT 1548 surg ICU pts blindly allocated to conventional tx (IV insulin if glc > 215 mg/dL) and intensive (IV insulin to maintain glc 80-110 mg/dL)  Findings: IIT reduced mortality, morbidity in critically ill surgery patients  Van den Berghe, G. et al (2001). NEJM, 345, 1359-1367
  53. 53. +
  54. 54. + Practice changed
  55. 55. +Hold on-Meta-analysis (2010)  “Tightglycemic control is associated with a high incidence of hypoglycemia and an increased risk of death in patients who do not receive parenteral nutrition”.  Marik, P.E. & Preiser, J. (2010). Chest, 137, (3)
  56. 56. + Hold on-Meta-analysis (2010) 7 RCTs pooled with 11,425 pts  IITdid not:  Reduce 28-day mortality (OR=.95 [CI, .87- 1.05]  Reduce BSI (OR=1.04 [CI, .93-1.17]  Reduce renal replacement tx (OR=1.01 [CI, .89-1.13]  IITdid:  Increase hypoglycemic incidents (OR=7.7 [CI, 6.0-9.9] Marik, P.E. & Preiser, J. (2010). Chest, 137, (3)
  57. 57. + Hold on-Meta-analysis (2010)  Meta-regression revealed:  Relationship between proportion of parenteral calories and 28-day mortality  Leuven trials tx effect related to parenteral feeding  Harm?  Mortalitylower in control (glc 150 mg/dl) OR=.9 [CI, .81-.99] when Leuven trials removed  Noevidence to support IIT in general med- surg ICU pts fed according to current guidelines (ie, enteral) Marik, P.E. & Preiser, J. (2010). Chest, 137, (3)
  58. 58. + hwww.flickr.com/photos/areAre there hazards when QI waitson EBP? namontanus/
  59. 59. What is the “ideal best” type of research evidence? Comparing Treatments Meta-analysis or systematic review of RCTs Determining extent of risk, Systematic review ofDiCenso, Guyatt & Ciliska (2005) predictive of future problem cohort, case-control studies Specificity/sensitivity of an Systematic review of Craig & Smyth, (2002) assessment/test blinded comparison of test and reference value Perceptions/values/beliefs Meta-syntheses of qualitative studies
  60. 60. +Back to ourstory…
  61. 61. + QI effort-implementing the evidence from SRs and using evidence-based strategies12 CAUTIs Jan 08 - June 09 Pre-intervention Rate at Audit 1:10 5.9/1000 cath days8 Rate at Audit 2:6 2.8/1000 cath days4 Title Average2 A/F 10 A/F 2 Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June
  62. 62. + How has QI been studied for its effectiveness? Researchmethods are “weak” and messy- tremendous research challenges  38% were RCTs and more likely to find no effect  62% were observational and more likely to find an effect Most studies could not be used beyond their local setting:  Too short to make cause/effect claims  Inadequate monitoring of the intervention  Self-selection bias prevalent  Complex interventions Alexander et al (2009) Med Care Res and Rev, 66, 235-
  63. 63. + Caveats  Mostof the hospital studies conducted in university-based hospitals  Publication bias likely  Focused more on physician practice  30% used multiple-interventions Alexander et al (2009) Med Care Res and Rev, 66, 235-
  64. 64. + “All three approaches have an important, yet different, relationship with knowledge:What do you  Research generates itthink of this  EBP translates itstatement?  QI incorporates it”Shirey et al, 2011 J Cont Ed inNursing, 42(2)
  65. 65. +  Embrace broader ideas about what counts as evidence-including local data but also embrace global evidence(Harvey)  EBP should learn from QI and vice versa to speed the spread and enhance rigor (Harvey)  Toolsthat work for the commonSynergies? goal of evidence translation, practice developed evidence  Enhanced point of care KT, through changes in evidence transfer  Evidence-based implementationHarvey, G. (2005) Worldviews, secondquarter, 52-4 strategies
  66. 66. How about a shift inparadigm: + Evidence-based Quality Improvement
  67. 67. Research EBP QI
  68. 68. Research EBPQI E-B QI
  69. 69. “Reliable knowledge has to be bothscientifically and socially robust.Knowledge can no longer bedetermined by narrowly definedscientific communities but by widercommunities of knowledgeproducers, disseminators, tradersand users.” Kitson, A. & Bisby, M. (2008). Speeding the spread. KT08
  70. 70. “Reliable knowledge has to be bothscientifically and socially robust.Knowledge can no longer bedetermined by narrowly definedscientific communities but by widercommunities of knowledgeproducers, disseminators, tradersand users.” Kitson, A. & Bisby, M. (2008). Speeding the spread. KT08
  71. 71. + Themes for “how” Shift in knowledge production: from Mode 1 to Mode 2 research paradigms to “speed the spread” of research evidence Theoretical models related to “how” are needed, some are evolving Beyond barriers to Knowledge Translation (KT)
  72. 72. + Researchers generate research questions and Mode 1 methodsKitson & Bisby , 2008) www.kusp.ualberta.ca/KT08documents.cfm Research Researchers conduct “Blue sky” data collection Curiosity driven Takes place in the bench lab or clinical Researchers lab disseminate findings at Traditional, linear the end of the study End of grant transfer (amongst themselves?)
  73. 73. + Mode 2Kitson & Bisby , 2008) www.kusp.ualberta.ca/KT08documents.cfm Researchers Research Socially distributed knowledge Negotiation/collaborati Users Multidisciplines on driven Takes place within New context of application Methods Transdisciplinary and Reflexive, dialogue, ite quality rative
  74. 74. + Models are Emerging  Knowledge-to-Action  PARIHS Evidence Context Facilitation SI = f (E, C, F) Kitson & Bisby ( 2008) www.kusp.ualberta.ca/KT08documents.cfm www.cihr-irsc.gc.ca/e/29418.html
  75. 75. + EngagementWhat are Transactionalcommon themes Nonlinearandcharacteristics Iterativeamong these Fuzzinessmodels that canguide Socialimplementation Contingentscience?
  76. 76. + How do you do get evidence into practice? Emerging Science: Knowledge Translation (KT)Knowledge translation is a dynamic and iterative processthat includes synthesis, dissemination, exchange andethically sound application of knowledge to improve thehealth of Canadians, provide more effective healthservices and products and strengthen the health caresystem. http://www.cihr-irsc.gc.ca/e/29418.html
  77. 77. + Beyond Barriers: Knowledge Translation (KT)Knowledge translation is a dynamic and iterative processthat includes synthesis, dissemination, exchange andethically sound application of knowledge to improve thehealth of Canadians, provide more effective healthservices and products and strengthen the health caresystem. http://www.cihr-irsc.gc.ca/e/29418.html
  78. 78. + 6 Opportunities for KT (CIHR, 2005) Publications KT3 KT1 KT2 Researchers Questions & Research Global Knowledge Methods Findings Knowledge Users KT4 KT6 Contexualization Impacts of Knowledge Application of Knowledge KT5As cited in Sudsawad, P. (2007) http://www.ncddr.org/kt/products/ktintro/
  79. 79. + 6 Opportunities for KT (CIHR as cited in Sudsawad, 2009) 1. Defining research questions/methods 2. Conducting participatory research 3. Publishing in plain language and accessible fashion 4. Putting findings in the context of other knowledge 5. Making decisions and taking action informed by findings 6. Influencing subsequent research based on impact of knowledge useAs cited in Sudsawad, P. (2007) http://www.ncddr.org/kt/products/ktintro/
  80. 80. + KT in the US T1-bench to clinical research T2-clinical research to practice
  81. 81. +What evidence exists tosupport getting andsustaining evidenceimplementation?
  82. 82. + Strategies that work better Reminders, cues Educational outreach Interactive education Didactic continuing education meetings -small effect on profession practice and less on patient outcomeBero et al, BMJ, (1998); Grimshaw et al, CochraneLibrary(2005); Forsetland et al (2009) Cochrane Library;Farmer et al., Cochrane Library (2008)
  83. 83. + Strategies that work better Multifaceted interventions (includes two or more: audit and feedback, reminders, local consensus processes or marketing) Interactive or combination interventions had greater impact and were more likely to affect complex interventionsBero et al, BMJ, (1998); Grimshaw et al, Cochrane Library(2005); Forsetland et al(2009) Cochrane Library; Farmer et al., Cochrane Library (2008)
  84. 84. + Strategies that may not work Passive distribution of educational materials Didactic educational meetings Interventions targeted at individual and organizational barriers need further study Bero, Grilli, Grimshaw, Harvey Haines and Donald, BMJ, 1998 Cheater et al, Cochrane Database of Reviews, 2005
  85. 85. +Evidence of Effectiveness ofCommon QI Efforts
  86. 86. +Audit and Feedback on Compliance withRecommended Practice 72 studies making 88 comparisons vs. no tx Risk difference ranged from 16% decrease to 70% increase in compliance (dichotomous vars.) 10% decrease to 68% increase (continuous vars) Low baseline compliance and higher intensity feedback associated with greater effectiveness Jamtvedt: The Cochrane Library, Vol.3. 2006 last update 5/06.
  87. 87. + VA experience with A/F-Quality Enhancement Research Initiative (QUERI)  Timely feedback  Individual performance feedback rather than aggregate  Non-punitive  Engage provider in process rather than as passive recipient Hysong et al, (2006). Audit and feedback and clinical practice guideline adherence: Making feedback actionable. Implementation Science, 1,9.
  88. 88. + Other lessons learned from QUERI  Thedoing and study of implementation are long-term investments  Significant resources must be devoted  Health systems should take on both the responsibility of doing best practices and supporting implementation research Graham and Tetroe (2009)
  89. 89. + SR: Lean, Six Sigma, StuderGroup Hardwiring 9 studies of Six Sigma; 9 Lean; 1 of StuderGroup (you know the one)  Universally, all claimed the interventions were effective But--all had significant threats to validity including weak designs, inappropriate or lack of statistical reporting, and failure to rule out alternative hypotheses including not analyzing control group results, even though they used one! Vest et al (2009) Implementation Science, 4:35
  90. 90. Tools and+ Infrastructure Human Technological Contextual
  91. 91. + IOM Roundtable on EBM Goal: By the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to- date clinical information, and will reflect the best available evidence.…the development of a learning healthcare system designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider, to drive the process of discovery as a natural outgrowth of patient care, and to ensure innovation, quality, safety, and value in health care.
  92. 92. + IOM’s goal based on: Learning health system-evidence generated and applied as a natural product of the care process Expanding comparative effectiveness evidence capacity IOM (2011)Learning What Improve public understanding of the Works,Infrastructure.. nature of evidence, the dynamic nature of evidence development, and the importance of insisting that care reflects the best evidence
  93. 93. + IOM Themes on Infrastructure: Planning builds to future needs Trained workforce forGlobalizing evidence evidence stewardship and localizing decisions Infrastructure for Learning Real-time data analysis Public-private capacities fuel effort Learning beyond bridging the research practice gap Coordinating work and ensuring HIT investment for standards real-time learning
  94. 94. + Human  Facilitation  Mentors  Communities of practice  Communication  Relationship building  Organizational Culture
  95. 95. + •Transformational leadership Leadership •Clear roles, effective team work •Effective organizational structure •Democratic, enabling/e mpowering approaches•Traditional, command, control leadership•Lack of roleclarity, teamwork•Poor organizationalstructure PARIHS model Rycroft-Malone•Autocratic decision-making (2004); Kitson et al, (2008)
  96. 96. + •Clear values/beliefs •Values Culture individuals, consistency •Emphasis on relationships •Resources allocated•Unclear values & beliefs•Task driven•Low regard for individuals•Lack of consistency PARIHS model Rycroft-Malone•Resources not allocated (2004); Kitson et al, (2008)
  97. 97. + •Internal measures used routinely Evaluation •Audit and feedback used routinely •Peer review •External measures •Multiple methods•Absence of: •Audit and feedback •Peer review •External audit PARIHS model Rycroft-Malone•Narrow use of performance (2004); Kitson etinformation sources al, (2008)
  98. 98. + Facilitation- Mentorship Enabling others
  99. 99. + Holistic- oriented Enabling others Purpose and Role •Sustained partnership •Developmental •Adult learning approaches •Internal/external agents •High intensity-limited Task-centered coverageDoing for others:•Episodic contact•Practical/technical help•Didactic, traditionalapproaches•External agents PARIHS model Rycroft-Malone•Low intensity-extensive (2004); Kitson etcoverage al, (2008)
  100. 100. + Skills and Attributes Holistic/enabling •Co-counseling •Critical reflection •Giving meaning •Flexibility of role •Authenticity Task/doing for•Project management skills•Technical skills•Marketing skills PARIHS model•Subjective/ technical/clinical Rycroft-Malone (2004); Kitson etcredibility al, (2008)
  101. 101. + Information Technology POC Access
  102. 102. “In the 21st century, knowledge isthe key element to improvinghealth. In the same way that peopleneed clean, clear water, they havea right to clean, clear knowledge” Sir Muir Gray Chief Knowledge Officer of NHS-UK
  103. 103. + Knowledge Management Aggregate: Put all your information sources in one place, it auto-updates and you can share it: NetVibes, iGoogle
  104. 104. + Knowledge Transfer http://plus.mcmaster.ca/np/Default.aspx http://www.tropika.net/svc/specials/KT- Toolkit/pages/KT-Toolkit
  105. 105. Where do you go first+ to find the best available evidence? How do you usually seek the evidence?Acquire Doyou have Internet access at the POC? What kinds of evidence are available at the POC?
  106. 106. + Currently, EB Clinical Guidelines in the US: Highly decentralized:  National Clearinghouse - 360 different organizationshttp://www.nap.edu/catalog.php?rehttp://www.rwjf.org/pr/product.jsp?i  471 guidelines related to HTNd=25351&c=EMC-CA142 or  276 guidelines related to stroke  But little guidance on other topicscord_id=120388
  107. 107. + Recommend single entity:  Buildfoundation for knowing what works in health care  Set priorities  Open  Transparenthttp://www.nap.edu/catalog.php?rehttp://www.rwjf.org/pr/product.jsp?i  Establish methodologic standards ford=25351&c=EMC-CA142 or systematic reviews  Develop clinical practice guidelinescord_id=120388  Transparency  Minimize bias
  108. 108. IOM’s Framework Research Studies Systematic Review: ID & assess studies Appraise body of evidence http://www.nap.edu/catalog.php?re http://www.rwjf.org/pr/product.jsp?i Synthesize d=25351&c=EMC-CA142 or cord_id=120388 Clinical Guidelines and Recommendations
  109. 109. + What works needed for policy to: Constrain cost Decrease geographic variationshttp://www.nap.edu/catalog.php?record_id=http://www.rwjf.org/pr/product.jsp?id=25351 Increase quality Consumer directed health care&c=EMC-CA142 or Making coverage decisions120388
  110. 110. Percapita
  111. 111. + Quick Action from 2008-11 AHRQ SR as method to Standardized compare IOM Systematic effectiveness of Review treatments Methods 2008 2009 2011
  112. 112. + Systematic reviews should: Identify gap between what we know and what we need to know Concise and transparenthttp://www.nap.edu/catalog.php?rehttp://www.rwjf.org/pr/product.jsp?id=25351&c=EMC-CA142 or Contradictory findings Provide narrative summary or pooledcord_id=120388 statistical analysis
  113. 113. + “An important barrier to the implementation ofPatient CPGPreferences recommendations isand their inability toImplementation reconcile patientScience preferences and values as well as social norms”Legare et al, 2009ImplementationScience, 4, 30
  114. 114. + How do you integrate pt preferences? Examine the source of information for public/consumer involvement in its development Develop/adopt plain language information for patients/family Engage a consumer in policy development Consider patient satisfaction scores in policy refinement Offer patient choice at POC No systematic approach Other?
  115. 115. + Lisa’s top picks for implementation resources  Cochrane Library:  Guidelines International  Effective Practice and Network Organisation of Care  www.g-i-n.net/ Group (EPOC)  www.cochrane.org  RNAO’s toolkit for guideline implementation  CIHR funded KT Clearinghouse  www.rnao.org  http://ktclearinghouse.ca/  JBI Global Learning cebm Centre  http://www.globallearningc entre.joannabriggs.edu.au /
  116. 116. The Issue Remains:Know-Do Gap

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