Knowledge TranslationMoving from Best Evidence

to Best Practice

Dr. Imad Salah Ahmed Hassan MD (UK) FACP FRCPI MSc MBBS

Consultant Physician & Pulmonologist

Chairman, Knowledge Translation Committee

Department of Medicine

KAMC

Riyadh

Kingdom of Saudi Arabia

imadsahassan@gmail.com

Q: What Scares

Doctors?

Patients

Colleagues

AdministrationA: Being Patients

Time cover story - May 1, 2006

Q: What Scares Doctors?

A: Being the Patient

Updated September 21, 2012, 10:56 p.m. ETHow to Stop Hospitals From Killing Us????Medical errors kill enough people to fill four jumbo jets a week

Stop making mistakes…STOP WORKING!

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 re-

occuring

What is KT & why

is it importan

t?

How to Do It? A Framework for KT.

Practical Example.

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

Knowledge Application (Action Cycle) includes:

1

•Identify the problem

2

•Measure Magnitude and Determine the Root-Cause

3

•Pass to your KT Team

4

•Find (& Appraise) the Evidence

5

•Assess barriers and facilitators to knowledge use.

6

•Adapt knowledge to local context

7

•Select and implementing interventions

8

•Monitor knowledge use: Process & Outcome

9

•Sustain knowledge use

Step 1: Identifying the problem- Identify the Knowledge-To-Action Gap

Resources: Gap or Error Detection

• Organization level:• Health records• Chart audits e.g. M&M reports

• Provider level:• Direct observation• Questionnaires

• Patient Level:• Patient Complaints• Questionnaires

Skills for Problem Detection

• Process Change Skills

Step 2: Identify the Magnitude of the Problem- (for future comparison post-intervention) & Its Root-Cause

Resources: Gap or Error Detection

• Organization level:• Health records• Chart audits e.g. M&M reports

• Provider level:• Direct observation• Questionnaires

• Patient Level:• Patient Complaints• Questionnaires

Skills/Tools for Root Cause Analysis/Detection

• Process Change Skills• Check Sheet• Cause-and-Effect Diagram• Flow Charting• Pareto Chart• Scatter Diagram• Probability Plot• Histogram• Control Charts• Brainstorming• 5 Whys Tool

Step 3: Pass to your KT Team

Composition of A KT Team

• Multidisciplinary• Clinicians• Pharmacists• Nursing• Trainees• Quality Mgt staff• Monitors • Statistician• Librarian (EBM)• Patient Representative

Skills/Tools for Team Work

• Process Change Skills• Roles:

• System leadership• Technical leadership• Day-to-day leadership

Step 4: Find the Evidence: Searching & Appraising Evidence

Resources: EBM Resources

• AHRQ Agency for Healthcare Research and Quality   http://www.ahrq.gov/

• NICE National Institute for Health and Clinical Excellence: www.nice.org.uk

• Guidelines Clearinghouse: http://www.guideline.gov/

Skills for EBM Practice

• EBM Skills• Ask• Acquire• Appraise

Step 5: Find the Barriers- Assess Barriers to Knowledge Use

Barriers to Change

• Organizational (Structure: equipment & Process: time)

• Individual• Knowledge• Attitude• Skills• Social (acceptability by

society & patients)

Skills for Management of Change

• Process Change Skills

Step 6: Adaptation Phase- Adapt Knowledge to Local Context (Adaptability)

Barriers to Use

• Adequate resources:

• Manpower• Economic/Financial• Leadership• Political• Etc.

Skills for Adaptation

• Process Change Skills• EBM Skills (The ADAPT

Tool)

Step 7: Find the Tools- Select, Tailor & Implement Interventions

Tools for Implementation

• Organization directed:• Legislation/Leadership

Commitment• Policies & Procedures -Reminder

Systems: Clinical Pathways, Order Sets, Check-lists

• System Redesign• Individual directed• Training Program• Certification• Patient directed :• Education, Partnership

agreements etc

Skills for Successful Implementation

• Process Change Skills• EBM Skills: Apply-

EBM Implementation Tools

• System Redesign

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)

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.

Structure• New Division e.g. KT Division• New Team e.g. Anticoagulation

Team• Revised Job-description e.g. KT

MonitorProcess• Redesign Training Programs

• Computerized Decision Support Systems

• Electronic Orders/Pathways/Protocols and Reminders

• SBAR• Checklists

Outcome• Patient Satisfaction Surveys• Staff Satisfaction Surveys

If you do not know where you want to go……… Implementation/KT websites Quality Improvement website

1. AHRQ Agency for Healthcare Research and Quality   http://www.ahrq.gov/2. NICE National Institute for Health and Clinical Excellence: www.nice.org.uk3. Clinical Improvement Skills:   http://www.improvementskills.org/index.cfm4. Institute for Healthcare Improvement:

http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/5. Knowledge Translation Clearinghouse: http://ktclearinghouse.ca/6. ICSI Institute for Clinical Systems Improvements  

http://www.icsi.org/index.aspx7.  Society of Hospital Medicine: http://www.hospitalmedicine.org/8. Innovations Exchange for New Ideas of Care http://innovations.ahrq.gov/

Step 8a: Monitor the Change- Monitor Knowledge Use (The Process)

Tools for Monitoring the

Process

• Process Variance (Audit)

• Knowledge use by providers:

• Knowledge use by patients:

Skills for MonitoringImplementati

on

• Process Change Skills

Step 8b: Monitor the Change- Monitor Knowledge Use (The Outcome)

Tools for Monitoring the

Process

• Outcome Variance (Audit)

• Impact on:• Patients• Providers• Organization

Skills for Monitoring

Implementation

• Process Change Skills

Step 9: Sustain the Improvement

Tools for Encouraging Compliance

• Regular Audit• Regular Update• Incentives• Competency-based

Training• Certification:

Individual & Organizational

Skills for Sustaining Change

• Process Change Skills

The necessary building blocks for successful KT based on the above:

Process Change skills EBM Skills Implementation of Change Tools System Redesign Skills KT Competency/Competency-Based Training

Curricula

The Five-Component Model for a Successful Knowledge Translation Undertaking

How Can I Do It???

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

Knowledge Application (Action Cycle) includes:

1

•Identifying the problem (Audit of Low Back Pain LBP care)

2

•Measure Magnitude and Determine the Root-Cause

3

•Pass to your KT Team

4

•Find (& Appraise) the Evidence

5

•Assess barriers and facilitators to knowledge use.

6

•Adapting knowledge to local context

7

•Selecting and implementing interventions (TOOLS)

8

•Monitoring knowledge use: Process & Outcome (LBP Monitor)

9

•Sustaining knowledge use: Re-audit, Update, Certify/Accredit

An Audit Cycle

KT for LBP: Implementation Tools

•Education, Back Pain Clinical Pathway, Checklists

Implementation Tools

•LBP Team, LBP Monitor,

•Electronic H&P, Order Set

System Redesign

Examples of Clinical Pathways

KT in Summary

Getting research into practice

Is a Complex but Achievable Task

Collective Effort

Organizational and Individual Responsibilities

Patient Right

BE M

Lessons from experienced guideline implementers: Attend to many factors and use multiple strategies. Journal of Quality Improvement 2000; 26(4):171-188.

Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 1998;317:465-468.

Evidence-based implementation of evidence-based medicine. Jt Comm J Qual Improv. 1999;25(10):503-13.

Translating guidelines into practice: A systematic review of theoretical concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CAN MED ASSOC J, 1997; 157 (4)409-416.

A guide to the development, implementation and evaluation of clinical practice guidelines. National Health and Medical Research Council. Commonwealth of Australia 1999.

Integrated care pathways. BMJ 1998;316:133-137.Using checklists and reminders in clinical pathways to improve

hospital inpatient care. MJA 2004; 181 (8): 428-431.

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