Knowledge TranslationMoving 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

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

reoccuring

Steps

How to Practice

KT?

Where Do I Go From

Here?

What is KT?

Objectives

To define & understand knowledge translation

To appreciate why KT is important

To provide a framework for knowledge translation

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

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”.

Healthcare is a System

Health Care Model: Donabedian Model

Process

Structure

OutcomeSix Ds:

DeathDiseaseDisabilityDiscomfortDissatisfactionDestitution (cost)

Care Process

Anatomy

• Pathways• Protocols• Physician

orders• Nursing Care• Housekeepin

g• Transport

• Staff• Department

s• Equipment• Supplies• Environme

nt

Basic Concepts in KT

Concept No.: 2

Organizational Structure Professional (Knowledge, Skill or Attitude

barriers) Social

Barriers to Successful KT

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

Basic Concepts in KT

Concept No.: 3

KT, Quality and Staff Competency are Interlinked

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

Knowledge

Attitude

Skills

"Fit for purpose“"Right first time"

“Quality improvement comes from changing

systems, not from working harder”

Systems Thinking

The SIX Domains of Quality Care

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.

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

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

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.

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.

The Five-Component Model for a Successful Knowledge Translation Undertaking

The Five-Component Model for a Successful Knowledge Translation Endeavour

EBM

Implementation of Change Tools

System Redesign

Process

Change Skills

KT Competency

Training

KT

EBM

Evidence-based Practice

Ask clinical questions

Acquire the best evidence

Appraise the evidence

Applyevidence to Your patient

5A’s !!Assess

effectiveness, efficiency of EBM

process

Acquire the Best Evidence

Pre-appraised, systematic reviews: Cochrane, DARE, Clinical Evidence, EPC Evidence Reports (in AHRQ)

Databases with EBM, background, and guideline info.: InfoRetriever®, DynaMed®, ACP’s PIER, Guideline Clearinghouse and USPSTF (in AHRQ), NICE

Highly referenced, current e-textbook: Up-to-Date, Scientific American

Standard e-textbooks, PDA e-textbook (5MCC)

PubMed (Clinical Queries), Medline

Pre-appraised, individual studies: InfoPOEMs, ACP Journal Club

*Adapted from Shaughnessy and Slawson

The Sources of Evidence Pyramid

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/

Implementation Tools

It is vitally important to note that both individual and

organizational factors need to be addressed for

successful implementation to take place.

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)

Barriers for Knowledge TranslationOrganisational 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

Unyielding leadership/regulatory body’s support both materially and in manpower.

Specialized/KT Clinical Teams & DivisionsMultidisciplinary teams: Stroke Team, Diabetes team, Heart Failure Team etcRevision of professional roles e.g. increased clinical roles to nurses and expanding the roles of pharmacistsCompulsory KT/EBM rotation/certification/ CME hours during training.

Organisational Interventions: STRUCTURES

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 principlesClinical Audit /Audit Department, Mortality and Morbidity Review.Regular assessment/feedback from end-users and health consumers e.g. questionnaires, self-report activities etc.

Organisational Interventions

Patient-and Patient-Group mediated Interventions*“Patient Values & Preferences” Patient Education Department. Methods of Educating Patients/Self-Management 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.

Organisational Interventions

Professional Interventions: PROCESS

Knowledge Attitude Skills

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.

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 decision-support 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.

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

Process Change Skills

Model for Improvement

Topic

Team

Objectives

Awareness

Brain-storming

Produce

Pilot

Implement

Monitor

Review/

Update

Process Change Skills

b

EBM

Knowledge Application

Knowledge application (action cycle) includes:1. Identifying the problem

2. Adapting knowledge to local context

3. Assessing barriers and facilitators to knowledge use

4. Selecting and implementing interventions

5. Monitoring knowledge use

6. Evaluating outcomes; and

7. Sustaining knowledge use.

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

KT for LBP: Actions

•Skills for Management of Change

Process Change

•Education & Training

EBM

•Education, Back Pain Clinical Pathway, Checklists

Implementation Tools

•LBP Team, LBP Monitor, Electronic H&P, Order Set

System Redesign

•EBM, Implementation Tools Development, Process Change, System redesign etc

Competency Training

KT in Summary

Getting research into practice

Is a Complex but Achievable Task

Collective Effort

Organizational and Individual Responsibilities

Patient Right

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