This document discusses the distinctions, synergies, and infrastructures needed to optimize patient outcomes through evidence based practice, research, and quality improvement. It compares the problem solving processes of quality improvement, evidence based practice, and clinical research. Quality improvement uses a systematic, data-driven approach to improve processes and outcomes, while evidence based practice involves using the best available research evidence, clinical expertise, and patient preferences to make decisions. Clinical research aims to generate generalizable knowledge through systematic study and evaluation. Infrastructure characteristics like mentorship, leadership, and culture can promote high quality outcomes, evidence uptake, and clinical inquiry.

1. +
Evidence Based
Practice, Research
and Quality:
Hedges (2006)
Distinctions, Synergies, and
Infrastructures to Optimize
Patient Outcomes
Clinical Fellows Graduation
TCU Lisa Hopp PhD, RN
Sept 21, 2011 ljhopp@purduecal.edu

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. +
Why do I ask?-It matters to the:
Problems Questions
you identify you ask
Alternative
Solutions
solutions you
you choose
generate

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. +
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. +
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. +
A Story About a
Problem

8. +
#
CAUTIs/10
Too Many 00 days
CAUTIs!
1st quarter

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. + Who is paying attention?

11. +
Clinical Research
EBP
QI
“Knowing is not enough;
we must apply. Willing is
not enough; we must do.”-
Goethe

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. Despite unprecedented advances in
+
biomedical knowledge and the
highest per capita health care
expenditures in the world, the
quality and outcomes of health care
for Americans vary dramatically
across the country. Improved
knowledge about which treatments
and procedures are effective could
lead to less regional differences,
stronger consensus on standards
and guidelines, and lower costs.
RWJ commissioned IOM to: IOM: Knowing
“Recommend a sustainable, What Works in
replicable approach to
identifying effective clinical
Healthcare (2008)
http://www.rwjf.org/pr/product.jsp?id=25351&c=EMC-CA142
services” or http://www.nap.edu/catalog.php?record_id=120388

14. Despite unprecedented advances in
+
biomedical knowledge and the
highest per capita health care
expenditures in the world, the
quality and outcomes of health care
for Americans vary dramatically
across the country. Improved
knowledge about which treatments
and procedures are effective could
lead to less regional differences,
stronger consensus on standards
and guidelines, and lower costs.
RWJ commissioned IOM to: IOM: Knowing
“Recommend a sustainable, What Works in
replicable approach to
identifying effective clinical
Healthcare (2008)
http://www.rwjf.org/pr/product.jsp?id=25351&c=EMC-CA142
services” or http://www.nap.edu/catalog.php?record_id=120388

15. +
Research Gaps,
Duplications and
Contradictions
IOM, 2008

16. + 

10 Nurse-Hospital Acquired Conditions
High cost, high volume, higher payment
“could reasonably
and
have been
Paying prevented through
the application of
Attention? evidence based
guidelines”

17. +
Habit
Paying
Active feedback
Attention?
No one excused
Data driven
Systems

18. +
Paying
Attention?

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. + 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.  “non-profit
+ organization to
assist patients,
clinicians, purchasers,
and policy- makers in
making informed health
2010 Affordable decisions by carrying out
Care Act
research projects that
provide quality, relevant
evidence on how diseases,
PCORI disorders, and other health
conditions can effectively
Patient-Centered and appropriately be
Outcomes prevented, diagnosed, treated,
Research Institute monitored, and managed.”
(GAO, 2010)

22. +
2010 Affordable
Care Act Increased emphasis on
systematic review as a
method to compare
PCORI effectiveness of
Patient-Centered treatments
Outcomes
Research Institute

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. +
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. +
Defining Characteristics of Nursing
Practice
Human Theory Nursing
Outcomes
Responses Application Actions
(effects)
(Phenomena) (Science) (EBP)
ANA, Social Policy
Statement (2010), p. 11

26. +
Magnet™ Recognition Infrastructure
Infrastructure Process
outcomes
Research,
EBP and
QI

27. +
 IOM
 CMS
 AHRQ
 JC
 ANA
 ANCC
EBP and Quality go hand-in-hand?

28. + Distinctions?

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. +
Key Questions
What is the effect…
What is the experience….
What is the relationship….
Etc…….

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. +
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. +
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. +
Implications of the Definition
Clinical
• Best Expertise • Meaning of
• Available • Criteria experiences
• Externalized • Individualized
Patient
Evidence Preferences

35. +
Best Available
• Right • Sources • Accessible
Available
Best
Feasible
evidence • Technique • User-
for the friendly
question • Exhaustive
• Relevant
• Pre-
appraised
• Standard
Appraisal
Tools

36. + Shift toward pluralistic,
inclusive definitions of
The Nature of what evidence is, and
Evidence (1996) subsequently of what
evidence based
practice is..
(Pearson et al,
2005)

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. +
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. +
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. +
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. +
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. +
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. +
Problem-Solving

44. +  What is the effect of
nursing stop-orders vs.
usual physician orders on
reinsertion rates, catheter
How would days and incidence of
the story go CAUTIs in uncomplicated,
non-urinary surgical
if Amanda… patients with short term
indwelling catheters?
Conducted clinical
research?

45. +  What is the effect of
nursing stop-orders vs.
usual physician orders on
reinsertion rates, catheter
How would days and incidence of
the story go CAUTIs in uncomplicated,
non-urinary surgical
if Amanda… patients with short term
indwelling catheters?
Was involved in an
evidence
implementation
project?

46. +  Catheter days and
incidence of CAUTIs in
surgical patients with
short term indwelling
How would catheters are too high.
the story go
if Amanda…
Was involved in a
QI project?

47. +
How did these stories compare:
Key Differences?
Research EBP QI
Goal Grow knowledge Close gap Best patient
for better pt between know outcomes, best
outcomes and do for best cost, and
pt outcomes regulatory
compliance
Relationship Generate or Synthesize, Systematically
with confirm new translate and optimize how
knowledge knowledge use knowledge to process
knowledge
Time required Longest but Longer but Aim for rapid but
variable variable variable
Designs Quant to qual Before-after with Before-after with
process monitor process monitor

48. +
How did these stories compare:
Key Differences?
Research EBP QI
IRB required Yes Sometimes Not usually
Flexibility Dependent upon Dependent Generally fluid
design-varies upon and locally
from rigid to more approach, but driven
fluid generally fluid
Funding Often external Usually internal, Part of usual
maybe external operational
funding
Time to Long term Short term Short term to
Impact immediate

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 naturalistic
Key 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. +
Are there hazards when QI=RU?

51. +
The
Intensive
Insulin
Therapy
Story
Target: 80-110 mg/dL

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. +

54. +
Practice changed

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. + 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. + 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. +
hwww.flickr.com/photos/are
Are there hazards when QI waits
on EBP?
namontanus/

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 of
DiCenso, 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. +
Back to our
story…

61. + QI effort-implementing the evidence
from SRs and using evidence-based
strategies
12
CAUTIs Jan 08 - June 09
Pre-intervention
Rate at Audit 1:
10
5.9/1000 cath days
8
Rate at Audit 2:
6
2.8/1000 cath days
4
Title
Average
2
A/F 1
0
A/F 2
Jan Feb Mar April May June July Aug Sept Oct Nov Dec Jan Feb Mar April May June

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. +
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. + “All three approaches
have an important, yet
different, relationship
with knowledge:
What do you  Research generates it
think of this  EBP translates it
statement?  QI incorporates it”
Shirey et al, 2011 J Cont Ed in
Nursing, 42(2)

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 common
Synergies? goal of evidence
translation, practice developed
evidence
 Enhanced point of care KT, through
changes in evidence transfer
 Evidence-based implementation
Harvey, G. (2005) Worldviews, second
quarter, 52-4
strategies

66. How about a shift in
paradigm:
+
Evidence-based Quality
Improvement

67. Research EBP
QI

68. Research EBPQI
E-B
QI

69. “Reliable knowledge has to be both
scientifically and socially robust.
Knowledge can no longer be
determined by narrowly defined
scientific communities but by wider
communities of knowledge
producers, disseminators, traders
and users.”
Kitson, A. & Bisby, M. (2008). Speeding the
spread. KT08

70. “Reliable knowledge has to be both
scientifically and socially robust.
Knowledge can no longer be
determined by narrowly defined
scientific communities but by wider
communities of knowledge
producers, disseminators, traders
and users.”
Kitson, A. & Bisby, M. (2008). Speeding the
spread. KT08

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. + Researchers generate
research questions and
Mode 1 methods
Kitson & 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. +
Mode 2
Kitson & 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. +
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. + Engagement
What are Transactional
common themes
Nonlinear
and
characteristics Iterative
among these
Fuzziness
models that can
guide Social
implementation
Contingent
science?

76. +
How do you do get
evidence into
practice?
Emerging Science:
Knowledge Translation
(KT)
Knowledge translation is a dynamic and iterative process
that includes synthesis, dissemination, exchange and
ethically sound application of knowledge to improve the
health of Canadians, provide more effective health
services and products and strengthen the health care
system. http://www.cihr-irsc.gc.ca/e/29418.html

77. +
Beyond
Barriers:
Knowledge
Translation (KT)
Knowledge translation is a dynamic and iterative process
that includes synthesis, dissemination, exchange and
ethically sound application of knowledge to improve the
health of Canadians, provide more effective health
services and products and strengthen the health care
system. http://www.cihr-irsc.gc.ca/e/29418.html

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
KT5
As cited in Sudsawad, P. (2007) http://www.ncddr.org/kt/products/ktintro/

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 use
As cited in Sudsawad, P. (2007) http://www.ncddr.org/kt/products/ktintro/

80. +
KT in the US
T1-bench to clinical research
T2-clinical research to practice

81. +
What evidence exists to
support getting and
sustaining evidence
implementation?

82. +
Strategies that work better
Reminders, cues
Educational outreach
Interactive education
Didactic continuing education
meetings -small effect on profession
practice and less on patient outcome
Bero et al, BMJ, (1998); Grimshaw et al, Cochrane
Library(2005); Forsetland et al (2009) Cochrane Library;
Farmer et al., Cochrane Library (2008)

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
interventions
Bero et al, BMJ, (1998); Grimshaw et al, Cochrane Library(2005); Forsetland et al
(2009) Cochrane Library; Farmer et al., Cochrane Library (2008)

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. +
Evidence of Effectiveness of
Common QI Efforts

86. +
Audit and Feedback on Compliance with
Recommended 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. +
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. +
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. +
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. Tools and
+
Infrastructure
Human
Technological
Contextual

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. +
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. + IOM Themes on Infrastructure:
Planning builds to future
needs
Trained workforce for
Globalizing 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. +
Human
 Facilitation
 Mentors
 Communities of practice
 Communication
 Relationship building
 Organizational Culture

95. + •Transformational
leadership
Leadership •Clear roles, effective
team work
•Effective organizational
structure
•Democratic, enabling/e
mpowering approaches
•Traditional, command, contr
ol leadership
•Lack of role
clarity, teamwork
•Poor organizational
structure PARIHS model
Rycroft-Malone
•Autocratic decision-making (2004); Kitson et
al, (2008)

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. + •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 et
information sources al, (2008)

98. + Facilitation-
Mentorship
Enabling others

99. + Holistic- oriented
Enabling others
Purpose and Role •Sustained partnership
•Developmental
•Adult learning
approaches
•Internal/external
agents
•High intensity-limited
Task-centered coverage
Doing for others:
•Episodic contact
•Practical/technical help
•Didactic, traditional
approaches
•External agents PARIHS model
Rycroft-Malone
•Low intensity-extensive (2004); Kitson et
coverage al, (2008)

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 et
credibility al, (2008)

101. +
Information Technology
POC Access

102. “In the 21st century, knowledge is
the key element to improving
health. In the same way that people
need clean, clear water, they have
a right to clean, clear knowledge”
Sir Muir Gray Chief Knowledge
Officer of NHS-UK

103. +
Knowledge Management
Aggregate: Put all your information
sources in one place, it auto-updates and
you can share it: NetVibes, iGoogle

104. +
Knowledge Transfer
http://plus.mcmaster.ca/np/Default.aspx
http://www.tropika.net/svc/specials/KT-
Toolkit/pages/KT-Toolkit

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. + Currently, EB Clinical Guidelines
in the US:
Highly decentralized:
 National Clearinghouse - 360 different
organizations
http://www.nap.edu/catalog.php?re
http://www.rwjf.org/pr/product.jsp?i
 471 guidelines related to HTN
d=25351&c=EMC-CA142 or
 276 guidelines related to stroke
 But little guidance on other topics
cord_id=120388

107. + Recommend single entity:
 Buildfoundation for knowing what works in
health care
 Set priorities
 Open
 Transparent
http://www.nap.edu/catalog.php?re
http://www.rwjf.org/pr/product.jsp?i
 Establish
methodologic standards for
d=25351&c=EMC-CA142 or
systematic reviews
 Develop clinical practice guidelines
cord_id=120388
 Transparency
 Minimize bias

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. + What works needed for policy
to:
Constrain cost
Decrease geographic variations
http://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 decisions
120388

110. Per
capita

111. +
Quick Action from 2008-11
AHRQ
SR as method to
Standardized
compare IOM
Systematic
effectiveness of
Review
treatments
Methods
2008 2009 2011

112. +
Systematic reviews should:
Identify
gap between what we know
and what we need to know
Concise and transparent
http://www.nap.edu/catalog.php?re
http://www.rwjf.org/pr/product.jsp?i
d=25351&c=EMC-CA142 or
Contradictory findings
Provide narrative summary or pooled
cord_id=120388
statistical analysis

113. + “An important barrier to
the implementation of
Patient CPG
Preferences recommendations is
and their inability to
Implementation reconcile patient
Science preferences and
values as well as
social norms”
Legare et al, 2009
Implementation
Science, 4, 30

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. + 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. The Issue
Remains:
Know-Do Gap