Getting Knowledge into Action to

Deliver the Future for Scotland’s Healthcare

Delivering the Future Residential Session17th January 2012

“Knowing is not enough; we must apply. Willing is not enough; we must do.”

- Goethe

Overview1. A new knowledge paradigm at the heart of

transformational leadership.

2. Practical tools for continuous co-creation of knowledge by combining content, communication, collaboration.

3. Discussion - knowledge into action supporting your clinical leadership role.

4. Where we are now – your role in leading knowledge into action….

Crossing the Quality Chasm

• The gulf between what we know is good quality care and what is the norm in practice.

Too much information….

“Seventy-Five Trials and Eleven Systematic Reviews a Day: How Will We Ever Keep Up?”

Bastian, H., Glasziou, P., Chalmers, I. PLOS-Medicine, 2010

Clinician would need to read at least 20 articles per day, 365 days per year, to keep up with new developments in their field.

Shaneyfelt, T. et al JAMA 2001

“The NHS is….. not good at capturing, using and sharing information. Lots of data, a lot less information and even less knowledge, and that's bad for patients and their families, it's bad for clinicians, bad for managers, bad for regulators and bad for policy-makers.”

Ann Abraham, Parliamentary and Health Service Ombudsman, reporting on Mid-Staffordshire Inquiry.

From Accessing to Applying Knowledge in NHS Scotland

Knowing• 66 libraries• 116 library staff• 12 million + resources

Doing• How much of this gets

used in a meaningful way to improve safe, effective, person-centred care?

Knowledge-practice gap

• 45% defect rate in US healthcare system – patients not receiving care as recommended in the evidence base. (McGlynn et al,2003)

• 30-40% defect rate in UK healthcare (Grol and Grimshaw, 2003)

• 17 years to get 14% of research recommendations into practice (Balas et al 2000)

What about care in 2011? NHS Atlas of Variation in Healthcare

Percentage of people in the National Diabetes Audit with Type 1 diabetes receiving all nine key care processes

Highest value is less than 50%.

Aim: Define a national system for knowledge management and utilisation in order to:

* help practitioners to apply knowledge to frontline practice.

* align use of knowledge with improving healthcare quality

* support practitioners and managers to translate knowledge into better health outcomes, i.e. safe, effective, person-centred, efficient care.

Knowledge into Action Review

A new lens for healthcare knowledge

Published research – our mainstay, but partial…

1. Evidence only available for 20% of clinical issues; rest is opinion (Williamson 1979, Sackett, 1995 and others).

2. Irreproducibility of research results (Naik, 2011)

3. Overestimation of impact in research studies compared with real-life contexts (Ioannidis, 2011).

4. Limitations in applying research results to individual patients with complex care needs and individual preferences. (Kent, 2007)

Changing the knowledge paradigm

• Continuously co-produce knowledge through collaboration with teams, patients and carers.

• Customise knowledge to context• Personalise knowledge to individual patient

care.• Understand, manage and use variation to

build the knowledge base.• Embed knowledge in clinical workflow

Recognise role of practice and experiential knowledge

• Need a new knowledge paradigm which constantly generates new knowledge by combining – research evidence– routine practice data – working experience of teams – lived experience of individual patients and carers.

• “Living guidelines” embedded in practice• Underpins continuous learning and continuous

improvement – research in action.

Example – Intermountain Healthcare

Brent James, Morris, Orme, 1998:• Created initial protocol for treating ARDS.• Placed by bedside as prompt / reminder in clinical workflow.• Clinicians encouraged to use as the default but to depart

from the protocol when necessary.• Reduction in variation through engagement enabled to

isolate the aspects of treatment that made a difference.• Weekly team meetings to review outcomes and reasons for

deviation from protocol – reviewed protocol to reflect reality of practice and patient need.

• 40% survival rate in ARDS compared with 10% survival as national average.

• Now extended to more than 50 clinical conditions.• Improving quality reduces cost.

Transfer of Knowledge into Quality Patient Care

Clinical Knowledge (Evidence Based Practice):

MEDLINE, Cochrane etc

Experiential Knowledge:

Practice, Patient, Context, System

Know-What

Know-How

Quality

Patient Care

Doing the right thing

Doing it right

Clinical Decisions

Process/System Changes

Adapted from: Glasziou, P et al. Can evidence-basedmedicine and clinical quality improvement learn fromeach other? 2011. BMJ Qual Saf 20 (suppl 1): i13-i17

Evidence Base

What approaches help to get knowledge into action to improve quality of care?

Huw Davies and Vicky Ward 2011

• Inquiry and synthesis• Actionable knowledge• Relational knowledge• Building organisational culture and capacity• Knowledge into Action roles

Examples (1)

Inquiry and synthesis

• Problem definition• Expert searches• Rapid evidence reviews• Capture tacit/experiential knowledge – case

studies, stories, social networking• Partner with information analysts to combined

data and research evidence.

Examples (2)

Actionable knowledgeSpecific evidence expressed as calls to action;

designed for use at point of clinical need.

• Pathways• Evidence bundles• Checklists• Prompts and reminders• Decision aids/decision support • Mobile apps• “Actionable knowledge”

Examples (3)

Relational knowledge• Communities of practice• One to one knowledge transfer (clinical

detailing)• Champions, opinion leaders• Interactive education• Social network mapping• Social networking and social media tools• Patient education and health literacy

Examples (4)

Organisational capacity and capability

• Workforce knowledge management skills• Knowledge broker roles• Defined knowledge management strategy

and policy

Build on KM expertise in:

* Evidence search, synthesis, packaging; * Facilitating sharing of knowledge- communities, 1-1 knowledge transfer;

* Planned dissemination and uptake

* Building workforce capabilities in K2A

Knowledge broker roles

Example –Knowledge into Action for Improvement

Problem

A mental health team leader identifies from readmissions data and complaints a need to improve cross-agency communication in care of schizophrenia patients on discharge from hospital.

Aim : Reliable communication for 95 % of patients with schizophrenia on discharge from hospital by June 2012

Know-what

He asks the knowledge manager to source and summarise the research evidence on interventions and outcome measures to improve cross-agency communication in care of schizophrenia patients discharged from hospital.

Know-how and know-who:

Knowledge management support to help implement new approaches effectively:

• Sourcing case studies• Published research – evaluations of implementation• Gathering good practice from communities of practice and

interviews with organisations facing similar challenges• Sharing stories with staff and service users• Peer assist sessions – identifying subject experts to

contribute their knowledge

Creating knowledge

Knowledge manager and team leader work together to create a checklist for use by NHS, partner agency staff, service users and carers (actionable knowledge).

They publish a summary of the new approach and a case study on the community website with links to the relevant evidence and guidelines (knowledge assets).

Discussion

• Think of a situation where your leadership role calls for you to translate knowledge into action.

• How could the knowledge into action approaches illustrated help you to improve healthcare quality in this situation?

Knowledge into Action in NHS Scotland

Current status and development path

“The future is already with us; it’s just not evenly distributed” William Gibson

Overview

• Current knowledge into action tools and services.

• National network of knowledge management support.

• Test of change projects – first steps in implementation.

Actionable Knowledge

Validated knowledge - designed for implementation in frontline practice

www.knowledge.scot.nhs.uk

Actionable Knowledge Services

Point of Care Knowledge

Decision Support “plug-in”

m.decisionsearch.scot.nhs.ukHomepage App Store

Creating actionable knowledge

• Publication tool – for pathways and SIGN guidelines.

• Decision support rules – to link with clinical systems.

Evidence search, synthesis, sharing

Example: Sepsis and VTE

Aim: Define and Implement Improvements for Management of Sepsis in VTE

Knowledge Management Support:• Evidence for intervention and implementation• Community of practice support• Territorial Board and Special Board partnership

Expert evidence search and synthesis

HIS and territorial board knowledge managers– Problem definition– “Know-what” clinical evidence for interventions

Cochrane, Medline, EMBASE etc.– “Know-how” and “know-who” examples of

implementation in US, UK; key contacts.

Community of Practice forSepsis and VTE

• Share and disseminate knowledge across boundaries of discipline and organisation.

• Peer support • Sharing ideas and learning • Combine published knowledge with personal

experience• Repository• Generate new knowledge • Translate knowledge into action

Library of communities

resources

Collaborative tools

Search box

Navigation

Boxes of functionality managed by

the administrato

rs of the website

Homepage of the community website

Log in with NHS Athens username

Tests of change

• 20 projects• 6 special boards, including State Hospital• 5 territorial boards• K2A areas:

– Expert search– Create and use actionable knowledge– decision

support, pathways, bundles etc.– Close interaction with clinical and programme teams

(social use of knowledge)– Coordinated KM teams

Examples

• Rapid search and synthesis for decision support in clinical settings. Virtual clinical librarian.

• Knowledge bundle to support perioperative care of diabetes patients

• Development of knowledge broker role for practice educators.

• Coordinating knowledge management roles across departments to support alcohol team.

Summing up

• Knowledge as a dynamic force for transformational change.

• Build organisational capacity to identify critical knowledge, blend into daily workflow and disseminate to all who need it, as actionable and relational knowledge.

“The transfer of knowledge is care”

Contacts

• Ann.wales@nes.scot.nhs.uk

• Karenritchie@nhs.net

• Annette.thain@nes.scot.nhs.uk

• Kevin.rooney@uws.ac.uk

Getting Knowledge into Action to

Deliver the Future for Scotland’s Healthcare

Delivering the Future Residential Session17th January 2012

“Knowing is not enough; we must apply. Willing is not enough; we must do.”

- Goethe