A stepwise practical guide for successfully completing a Knowledge Translation intervention.

1. Knowledge Translation
Moving 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

2. Patients
Colleagues
Q: What
Scares
Doctors?
A: Being
Patients
Administration

3. Time cover story - May 1, 2006
Q: What Scares
Doctors?
A: Being the Patient

4. Updated September 21, 2012, 10:56
p.m. ET
How to Stop Hospitals From
Killing Us????
Medical errors kill enough people to
fill four jumbo jets a week
Stop
making
mistakes…
STOP
WORKING!

5. 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%)
Conclusion: The “Defect Rate” in the technical
quality of American health care is approximately
45%!!!!!!!
McGlynn, et al: The quality of health care delivered to adults in the United States. NEJM 2003; 348: 2635-264 .

6. “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/

8. 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

9. What is
KT & why
is it
important?
How to Do
It? A
Framewor
k for KT.
Practical
Example.

10. Many terms, same basic idea …
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Applied health research
Diffusion
Dissemination
Getting knowledge into
practice
Impact
Implementation
Knowledge communication
Knowledge cycle
Knowledge exchange
Knowledge management
Knowledge translation
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Knowledge to action
Knowledge mobilization
Knowledge transfer
Linkage and exchange
Participatory research
Research into practice
Research transfer
Research translation
Transmission
Utilization

11. 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

12. E
E
to
B
M
P
Bridging the Gaps
 Knowledge
Practice
 Resources
Expenditure

13. 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:II46II54.
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.

14. Progress
Bridging the Implementation
Gap
Scientific
understanding
Implementation
Gap
Patient care
Time

15. 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; 6570

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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, Checklists
• System Redesign
• Individual directed
• Training Program
• Certification
• Patient directed :
• Education, Partnership
agreements etc
Skills for Successful
Implementation
• Process Change Skills
• EBM Skills: ApplyEBM Implementation
Tools
• System Redesign

24. Hierarchy of Evidence-Based
Implementation Tools
The Implementation
Pyramid
Interventions
of variable
effectiveness
•Audit and
feedback
•Use of local
opinion leaders
•Local consensus
processes
(ownership)
•Patient mediated
interventions
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)
* (a combination that includes two or more of the following: audit and feedback, reminders, local consensus
processes, or marketing)

25. 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.

26. StructureDivision e.g. KT Division
• New
• New Team e.g. Anticoagulation
Team
• Revised Job-description e.g. KT
Monitor
Process
• Redesign Training Programs
• Computerized Decision Support
Systems
• Electronic
Orders/Pathways/Protocols and
Reminders
• SBAR
• Checklists
Outcome
• Patient Satisfaction Surveys
• Staff Satisfaction Surveys

27. If you do not know where you
want to go………


1.
2.
3.
4.
5.
6.
7.
8.
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
Society of Hospital Medicine: http://www.hospitalmedicine.org/
Innovations Exchange for New Ideas of Care http://innovations.ahrq.gov/

28. 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

29. 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

30. 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

31. 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

32. The Five-Component Model for a Successful Knowledge
Translation Undertaking

33. How Can I Do
It???

34. 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.

35. 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, nonmechanical 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

36. Documentation of RED Flags in
LBP Referrals to PT: POOR KT!
 USA




Saddle Anesthesia
Night Pain
LL Neurodeficits
Bladder Dysfunction
19% of Cases
68%
19%
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.

37. Physical Therapists’ Use of Interventions With High
Evidence of Effectiveness in the Management of a
Hypothetical 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%

38. Physical Therapists’ Use of Interventions With High
Evidence of Effectiveness in the Management of a
Hypothetical 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

39. 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

40. An Audit Cycle

41. KT for LBP: Implementation Tools
Implementation
Tools
• Education, Back Pain
Clinical Pathway,
Checklists
System
Redesign
• LBP Team, LBP Monitor,
• Electronic H&P, Order Set

42. Examples of Clinical Pathways

45. KT in Summary
Getting research into practice
Is a Complex but Achievable
Task
Collective Effort
Organizational and Individual
Responsibilities
Patient Right

46. E
B
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.
M